Senior Transplant Case Manager - Hybrid

Blue Shield of CA; Virginia Beach (VA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to lead and execute care planning with a strong clinical focus. The role involves assessing members and developing plans in collaboration with nurses and treating physicians, particularly around chronic conditions and high ER utilization.

The position requires an active RN license, a nursing degree (BSN preferred), and CCM certification or progress toward certification. Hybrid virtual work is available with occasional in-office needs.

Qualifications

• Requires a CA RN license or valid RN license in another state.
• Associate's Degree in Nursing is required.
• BSN or higher degree is preferred.
• CCM certification or in progress when eligible.
• At least 5 years of nursing, healthcare, or related experience.
• Prior transplant experience is required.
• Desires 3 years of managed care experience.
• Ability to assess, evaluate, and interpret clinical information for care planning.
• Extensive knowledge of evidence-based clinical guidelines for chronic conditions.
• Knowledge of Medicare regulations, prior authorization, level of care and LOS criteria.
• Proficient with PC-based software including Word, Excel, Outlook and Teams.

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment.
• Collaborate with members, clinical nurses and treating MDs on care planning.
• Triagem hub, chronic conditions, poly-pharmacy, prenatal care, and health assessments.
• Apply professional judgment to determine medical necessity and quality care.

Skills

RN license

CCM Certification

Associate's Degree in Nursing

BSN preferred

5+ years nursing experience

Transplant experience

Managed care experience

Clinical assessment

Evidence-based guidelines

Medicare coordination

Office 365 proficiency

Care coordination knowledge

Critical thinking

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing or higher

Tools

Microsoft Office 365

Word

Excel

Outlook

Teams

Job description

Blue Shield of CA is seeking a Senior Case Management Nurse to lead and execute care planning with a strong clinical focus. The role involves assessing members and developing plans in collaboration with nurses and treating physicians, particularly around chronic conditions and high ER utilization.

The position requires an active RN license, a nursing degree (BSN preferred), and CCM certification or progress toward certification. Hybrid virtual work is available with occasional in-office needs.