Care Management - Nurse, Senior - Transplant

Blue Shield of California•El Dorado, AR

1d•Hybrid

About The Position

The Case Management Nurse, Senior 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. The role determines, develops, and implements plans of care based on accurate member assessments and current or proposed treatment plans. Cases may involve member inquiries, triage, chronic conditions, poly-pharmacy, prenatal care, voluntary member health assessments, and multiple monthly emergency-room visits. The nurse designs and adjusts appropriate, fiscally responsible plans of care with targeted interventions to improve quality, access, and cost-effective outcomes. The role assesses members’ health behaviors, cultural influences, beliefs, and values; evaluates treatment information against clinical practice guidelines; and identifies potential barriers. The nurse also conducts care reviews with medical groups or providers for continuity-of-care, out-of-area or out-of-network, and investigational or experimental cases. The position reports to the Manager, Care Management. This role allows employees to work virtually full-time, with office attendance as required by business needs.

Requirements

Current and valid California RN license or valid RN license(s) from other state(s); preferred licensure from a compact state.
If assigned to another state, maintain an active, unrestricted RN license in the assigned state(s), or obtain the required additional RN 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 under 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.
Preferred licensure from a compact state.
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 healthcare services based on medical necessity and applicable plan contracts.
Refer members to Quality Management, Disease Management, and Appeals and Grievance departments as appropriate.
Recognize members’ right to self-determination and informed choice, including choices that may not promote the outcomes preferred by the healthcare team.
Design appropriate, fiscally responsible plans of care with targeted interventions to enhance quality, access, and cost-effective outcomes.
Initiate and implement modifications to plans of care as circumstances change over time and across settings.
Conduct member care reviews with medical groups or individual providers for continuity-of-care, out-of-area or out-of-network, and investigational or experimental cases.
Assess members’ health behaviors, cultural influences, beliefs, and values; evaluate treatment information in accordance with clinical practice guidelines and identify potential barriers.
Research opportunities to improve assessment methodology and promote continuous improvement.
Anticipate potential barriers and establish realistic goals to support successful outcomes for members, providers, and BSC.
Adjust plans or create contingency plans as necessary.
Continuously assess and reevaluate members’ health and progress, and modify plans of care as needed.