Senior Transplant Case Manager - Hybrid/Remote

Blue Shield of CA; Hartford (CT); Hybrid; USD 95,000 - 130,000; Full time

Job summary

The Case Management Nurse, Senior at Blue Shield of CA will lead case management activities, applying clinical judgment to develop and implement plans of care for members with complex needs. You will work with nurses and treating MDs, triage inquiries, and coordinate care across services.

This hybrid role requires 5+ years of nursing experience, transplant exposure, and CCM certification or active pursuit. Strong knowledge of guidelines and Medicare/PA processes is essential.

Qualifications

• Must hold a current CA RN License or RN license from another state; compact state preferred.
• Associate's Degree in Nursing is required.
• BSN or higher degree preferred.
• CCM Certification or in process of obtaining.
• Minimum 5 years of nursing/healthcare experience; transplant experience required.
• 3 years of managed care experience preferred.
• Ability to assess, evaluate, and interpret clinical information and care plans.
• Knowledge of evidence-based guidelines for chronic conditions.
• Demonstrates professional judgment and critical thinking for medical necessity.
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, LOS criteria desirable.
• Proficient with Microsoft Office 365 (Word, Excel, Outlook, Teams).

Responsibilities

• Determine, develop and implement the plan of care based on assessment and current treatment plans.
• Collaborate with members, clinical nurses and treating MDs as part of care management.
• Independently assess medical necessity promoting quality, cost-effective care.
• Report to the Manager, Care Management and contribute to team goals.

Skills

RN license

Assoc. Degree in Nursing

BSN or higher

CCM Certification

5+ years nursing/healthcare

Transplant experience

3 years managed care

Clinical assessment & care planning

Evidence-based guidelines knowledge

Medical necessity judgment

Coordination of Care/Medicare/PA/LOS

Office 365 proficiency

Education

Associate's Degree in Nursing

Bachelor of Science in Nursing or higher

Tools

Microsoft Office 365

Job description

The Case Management Nurse, Senior at Blue Shield of CA will lead case management activities, applying clinical judgment to develop and implement plans of care for members with complex needs. You will work with nurses and treating MDs, triage inquiries, and coordinate care across services.

This hybrid role requires 5+ years of nursing experience, transplant exposure, and CCM certification or active pursuit. Strong knowledge of guidelines and Medicare/PA processes is essential.