Nurse Case Manager Senior

7 days ago


Long Beach, California, United States Blue Shield of California Full time
Job Summary:

We are seeking a skilled Nurse Case Manager Senior to oversee patient care coordination in outpatient settings. This role involves developing individualized care plans, collaborating with healthcare professionals, and conducting health assessments to ensure the appropriate management of patient needs.

About Us:

Blue Shield of California is a leading health insurance organization dedicated to providing high-quality care to our members. Our mission is to improve the health and well-being of our community through innovative programs and services.

Salary:

The estimated salary for this role is $104,615 per year in California.

Responsibilities:
  • Research and design treatment/care plans to promote quality of care and cost-effective health services based on medical necessity
  • Initiate timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in, and documentation of interdisciplinary meetings (ICT)
  • Determine appropriateness of referral for CM services, mental health, and social services
  • Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance department (AGD)
  • Conduct member care review with medical groups or individual providers for continuity of care, out-of-area/out-of-network, and investigational/experimental cases
  • Manage member treatment to meet recommended length of stay; ensure DC planning at levels of care appropriate for the member's needs and acuity
Requirements:
  • Current CA RN License
  • Bachelor's of Science in Nursing or advanced degree preferred
  • Generally requires moderate to extensive experience in nursing, healthcare, or related field
  • Requires 5+ years' experience in nursing, healthcare, or related field
  • 3+ years managed care experience preferred
  • Certified Case Manager (CCM) Certification or in process of completing certification when eligible based on CCM application requirements
  • A minimum of 3 years experience in inpatient, outpatient, or managed care environment preferred
  • Health insurance/managed care experience desired
  • Transitions of care experience desired
  • Excellent communications skills
  • Experience in Maternity preferred


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