Care Management - Nurse, Senior

About the role

The Care Management team independently manages complex and high-risk care management cases by applying advanced clinical judgment to assess medical necessity, develop cost-effective care plans, and support quality outcomes aligned with benefit and contract requirements. You will collaborate with providers, medical directors, and interdisciplinary teams to coordinate care, support discharge planning, evaluate barriers to care, and ensure members receive appropriate referrals and continuity of treatment.

Responsibilities

• Work with minimal supervision to manage complex care management cases
• Apply advanced clinical judgment to assess medical necessity and appropriateness of care
• Design and implement treatment and care plans that promote quality, cost-effective outcomes aligned with benefit and contract requirements
• Collaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuity
• Determine appropriateness of referrals to care management and specialty programs
• Evaluate member health behaviors, cultural influences, and belief systems to identify barriers to care
• Contribute clinical input to medical directors and support informed decision making
• Continuously improve outcomes by anticipating barriers and adjusting plans of care based on reassessment, clinical changes, and guideline updates
• Maintain current knowledge of healthcare service trends, regulations, and clinical practice guidelines
• Ability to work evenings and weekends as part of rotating on-call schedule

Qualifications

• Associate Degree in Nursing required or master's degree in relevant field for non-RN licensure. Bachelor of Science in Nursing is preferred
• 5 years of experience in nursing, healthcare, or a related clinical field
• 3 years of managed care experience preferred
• Certified Case Manager (CCM) is preferred
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans
• Advanced knowledge of evidence-based clinical practice guidelines, particularly for chronic conditions
• Demonstrated competence in care management functions and standards of practice
• Knowledge of community resources, treatment options, home health services, funding sources, and specialty programs
• Working knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferred
• Knowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferred