Nurse Care Coordinator Senior

7 days ago


Rancho Cordova, California, United States Blue Shield of California Full time
Senior Nurse Care Coordinator Role Overview

We are seeking a highly skilled and experienced Senior Nurse Care Coordinator to join our team at Blue Shield of California.

About the Role:

  • Coordinate and manage patient care services in outpatient settings, designing and implementing individualized care plans while ensuring continuity of care and compliance with clinical guidelines.
  • Work closely with healthcare professionals, patients, and family members to develop and implement effective care plans that promote quality outcomes and improve patient experiences.
  • Utilize strong clinical knowledge, excellent communication skills, and problem-solving abilities to navigate complex healthcare scenarios and ensure seamless transitions of care.
Responsibilities:
  • Research and design treatment/care plans to promote quality care, cost-effective health services, and adherence to medical necessity guidelines.
  • Initiate timely individualized care plans (ICPs) based on health risk assessments (HRAs), interdisciplinary meetings (IDMs), and transitions of care across all ages.
  • Determine appropriateness of referrals for CM services, mental health, and social services, providing referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance departments (AGDs).
  • Conduct member care reviews with medical groups or individual providers for continuity of care, out-of-area/out-of-network cases, and investigational/experimental treatments.
  • Manage member treatment to meet recommended lengths of stay, ensuring DC planning at levels of care appropriate for members' needs and acuity.
  • Evaluate members' health behaviors, cultural influences, and client belief/value systems, identifying potential barriers and developing realistic goals and objectives.
Requirements:
  • Current CA RN License
  • Bachelor of Science in Nursing or advanced degree preferred
  • Certified Case Manager (CCM) Certification or in process of completing certification when eligible
  • At least 5 years of prior experience in nursing, healthcare, or related field
  • A minimum of 3+ years managed care experience in inpatient, outpatient, or managed care environment preferred
  • Health insurance/managed care experience preferred
  • Transitions of care experience preferred
  • Excellent communication skills
Salary Information:

The estimated salary range for this role is $87,230.00 to $130,900.00 per year, based on location and experience.



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