Care Management - Nurse, Senior

About the role

The Care Management team performs case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved in members' care, including clinical nurses and treating physicians. The Care Management Nurse, Senior will report 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 such as member inquiries, triage hub, chronic conditions, poly-pharmacy, pre-natal care, voluntary member health assessments, and indications of multiple monthly ER visits.

Our leadership model focuses on developing great leaders at all levels and creating opportunities for personal, professional, and financial growth. We seek leaders energized by creative and critical thinking, building high-performing teams, achieving results ethically, and fostering continuous learning. This position requires PST business hours.

Responsibilities

• Research and design treatment/care plans to promote quality of care and cost-effective healthcare services based on medical necessity, complying with contracts for each appropriate plan type.
• Provide referrals to Quality Management (QM), Disease Management (DM), and Appeals and Grievance Department (AGD).
• Recognize the client’s right to self-determination, including the right to make informed choices that may not align with the healthcare team’s recommendations.
• Design fiscally responsible plans of care with targeted interventions to enhance quality, access, and cost-effective outcomes.
• Initiate and implement modifications in the plan of care to adapt to changes over time and across settings.
• Conduct member care reviews with medical groups or providers for continuity of care, out-of-area/out-of-network cases, and investigational/experimental treatments.
• Assess members’ health behaviors, cultural influences, and belief/value systems.
• Evaluate all information related to current/proposed treatment plans in accordance with clinical practice guidelines to identify potential barriers.
• Research opportunities for improvement in assessment methodology and promote continuous improvement.
• Anticipate potential barriers while establishing realistic goals to ensure success for members, providers, and the organization.
• Adjust plans or create contingency plans as necessary, re-evaluating health and progress due to the dynamic nature of care plans.

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 a related field.
• At least 3 years of managed care experience preferred.
• 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.
• Ability to incorporate 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 sets preferred.
• Proficiency in Microsoft Office 365 applications, including Word, Excel, Outlook, and Teams.

Work Arrangement

This role allows for full-time virtual work, though employees may be required to come to the office based on business needs.

About Us

As of January 2025, Blue Shield of California became a subsidiary of Ascendium, a nonprofit corporate entity that includes Blue Shield of California, Blue Shield of California Promise Health Plan, Altais (a clinical services company), and Stellarus (a company designed to scale healthcare solutions). Together, these organizations form the Ascendium Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends—one that is sustainably affordable. We are transforming healthcare by lowering costs, improving quality, and enhancing the member and physician experience. Our workplace fosters an environment where all employees can thrive and contribute to addressing the needs of the communities we serve.

Blue Shield has been recognized as a U.S. News Best Company to Work For, a Deloitte U.S. Best Managed Company, and a Top 100 Inspiring Workplace. We were also acknowledged by Fair360 as a Top Regional Company and by Points of Light as one of the 50 most community-minded companies in the United States.

Values

• Honest: We uphold the highest ethical and integrity standards, building trust by doing what we say and correcting shortcomings.
• Human: We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous: We stand up for our beliefs and commit to the hard work necessary to achieve ambitious goals.

Workplace Model

We foster a workplace environment that balances purposeful in-person collaboration with flexibility, providing clear expectations while respecting diverse workforce needs. Most teams come into the office two days per week. Employees living more than 50 miles from an office, out-of-state employees, and those in certain member-facing roles should work with their manager to determine in-office time based on business needs. For employees with medical conditions impacting their ability to work in-office, we engage in an interactive process to provide reasonable accommodations.

Physical Requirements

This role involves part- to full-time work in an office environment, including deskwork. The activity level is sedentary for most of the workday.

Pay

• California: $90,860.00 to $136,290.00
• Out of State: $82,600.00 to $123,900.00
• Bay Area: $102,424.00 to $153,636.00

Salaries are based on candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.

Schedule

Full time.

Locations

AZ, WA, OH, DC, CA, CO, CT, FL, GA, MD, MN, NV, OR, AL, IL, VA, WI, TX (United States).