Blue Shield of CA
Case Management - Nurse, Senior
Blue Shield of CA, Los Angeles, California, United States, 90079
Your Role
The Case Management team performs case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care, including clinical nurses and treating MDs. The Case Management Nurse, Senior reports to the Manager, Care Management. In this role, you will determine, develop, and implement the plan of care based on accurate assessment of the member and current or proposed treatment plans in cases of: member inquiry, triage hub, chronic conditions, poly-pharmacy, pre-natal care, voluntary member health assessments, and indications of multiple monthly ER visits.
Your Knowledge and Experience Bachelor of Science in Nursing or an advanced degree is preferred.
Requires a current CA RN License.
Certified Case Manager (CCM) Certification or in the process of completing certification when eligible based on CCM application requirements.
Requires at least 5 years of prior experience in nursing, healthcare, or a related field.
Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
Extensive knowledge of evidence-based clinical practice guidelines, particularly for chronic conditions.
Uses professional judgment and critical thinking when determining medical necessity to promote quality, cost-effective care.
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria is desirable.
Able to operate PC-based software programs, including proficiency in Microsoft Office 365 applications such as Word, Excel, Outlook, and Teams.
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Your Knowledge and Experience Bachelor of Science in Nursing or an advanced degree is preferred.
Requires a current CA RN License.
Certified Case Manager (CCM) Certification or in the process of completing certification when eligible based on CCM application requirements.
Requires at least 5 years of prior experience in nursing, healthcare, or a related field.
Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
Extensive knowledge of evidence-based clinical practice guidelines, particularly for chronic conditions.
Uses professional judgment and critical thinking when determining medical necessity to promote quality, cost-effective care.
Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria is desirable.
Able to operate PC-based software programs, including proficiency in Microsoft Office 365 applications such as Word, Excel, Outlook, and Teams.
#J-18808-Ljbffr