Care Management - Nurse, Senior - Transplant

Blue Shield of California•El Dorado Hills, CA

1d•$90,860 - $153,636•Hybrid

About The Position

The Senior Care Management Nurse performs case management activities using clinical judgment and independent analysis, collaborating with members and others involved in their care, including clinical nurses and treating physicians. Reporting to the Manager, Care Management, this role assesses members and their current or proposed treatment plans and determines, develops, and implements plans of care in situations such as member inquiries, triage hub cases, chronic conditions, poly-pharmacy, pre-natal care, voluntary member health assessments, and multiple monthly emergency room visits. The role designs and revises plans of care to support quality, access, and cost-effective outcomes while considering medical necessity, applicable contracts, clinical practice guidelines, member preferences, and changing circumstances across care settings. The position is designated as hybrid virtual work and allows employees to work virtually full-time, with office attendance as required by business needs. The broader workplace model emphasizes purposeful in-person collaboration and flexibility; many teams come to the office two days per week, while attendance arrangements may vary by location, role, and business need. The position is based in an office/work-from-home setting and is sedentary for most of the workday.

Requirements

Current and valid California RN license or valid RN license(s) from other state(s); if assigned to another state, maintain an active, unrestricted license in that state or be able to obtain the required additional license within 90 days of hire.
Associate’s Degree in Nursing.
Certified Case Manager (CCM) certification, or be in the process of completing certification when eligible based on CCM application requirements.
At least 5 years of prior experience in nursing, healthcare, or a related field.
Prior transplant experience.
Ability to independently assess, evaluate, and interpret clinical information and develop care plans.
Extensive knowledge of evidence-based clinical practice guidelines, particularly for chronic conditions.
Ability to apply professional judgment and critical thinking when determining medical necessity to promote quality, cost-effective care.
Ability to operate PC-based software, including Microsoft Office 365 applications such as Word, Excel, Outlook, and Teams.

Nice To Haves

Bachelor of Science in Nursing or an advanced degree.
RN licensure from a compact state is preferred.
Three years of managed care experience.
Knowledge of coordination of care, Medicare regulations, prior authorization, and level-of-care and length-of-stay criteria sets.

Responsibilities

Research and design treatment and care plans that promote quality and cost-effective health care services, based on medical necessity and the contract for each appropriate plan type.
Refer members to Quality Management, Disease Management, and Appeals and Grievance departments as appropriate.
Recognize members’ right to self-determination and informed choices, including choices that may not promote the outcomes preferred by the healthcare team.
Design fiscally responsible plans of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
Initiate and implement appropriate changes to plans of care as circumstances change over time and across care settings.
Conduct member care reviews with medical groups or individual providers involving continuity of care, out-of-area or out-of-network care, and investigational or experimental cases.
Assess members’ health behaviors, cultural influences, beliefs, and values; evaluate treatment-plan information against clinical practice guidelines to identify potential barriers.
Research opportunities to improve assessment methods and promote continuous improvement.
Anticipate potential barriers and establish realistic goals to support successful outcomes for members, providers, and Blue Shield of California.
Adjust plans of care or create contingency plans as needed.
Assess and reevaluate member health and progress on an ongoing basis, modifying care plans in response to changing needs.