Senior Transplant Case Manager | RN (Hybrid)

Blue Shield of CA; Phoenix (AZ); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Case Management Nurse to join the Case Management team. You will determine, develop, and implement plans of care based on accurate member assessment, current or proposed treatment plans, and coordination with clinicians and care teams.

The role emphasizes independent analysis for chronic conditions, polypharmacy, prenatal care, and addressing frequent ER visits, with hybrid virtual work and periodic office attendance.

Qualifications

• Currently licensed RN in CA or other states; compact state licensure preferred; must maintain active license in assigned state(s)
• Associate's Degree in Nursing required
• BSN or higher degree preferred
• CCM certification or in process
• At least 5 years of nursing/healthcare experience
• Prior transplant experience required
• 3 years of managed care experience preferred
• Ability to independently assess, evaluate, and interpret clinical information and care planning
• Extensive knowledge of evidence-based clinical practice guidelines for chronic conditions
• Judgment and critical thinking to determine medical necessity for quality/cost-effective care
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and LOS criteria
• Proficiency in PC-based software including Word, Excel, Outlook and Teams

Responsibilities

• Determine, develop and implement the plan of care based on accurate assessment and current or proposed treatment plan in collaboration with members and care teams
• Collaborate with members, nurses, treating MDs and care teams to manage cases including high ER visits and complex needs

Skills

RN licensing and regulation

Critical thinking

Care planning

Independent assessment

Medical necessity evaluation

Chronic care guidelines

Coordination of care

Office 365 proficiency

Education

Associate's Degree in Nursing

BSN or higher degree preferred

CCM Certification or in progress

Tools

Microsoft Word

Excel

Outlook

Teams

Job description

Blue Shield of CA is seeking a Senior Case Management Nurse to join the Case Management team. You will determine, develop, and implement plans of care based on accurate member assessment, current or proposed treatment plans, and coordination with clinicians and care teams.

The role emphasizes independent analysis for chronic conditions, polypharmacy, prenatal care, and addressing frequent ER visits, with hybrid virtual work and periodic office attendance.