Blue Shield of CA

Compensation

Full Description

Your Role We invite you to become a vital part of our Case Management team as a Lead Case Management Nurse. In this important position, you will use your clinical expertise to deliver outstanding care to our members. You will manage comprehensive case management activities, using your clinical judgment and analytical skills to connect effectively with members, nursing staff, and healthcare providers. Your key responsibilities will encompass assessing members' needs, crafting and executing customized care plans, and responding to inquiries regarding chronic conditions, polypharmacy, prenatal care, and frequent emergency room visits. Our commitment lies in nurturing great leaders at all levels and enhancing both personal and professional growth. If you excel in a fast-paced setting, enjoy engaging in critical thinking and problem-solving, and are eager to build high-performing teams, we would love to hear from you! Your Knowledge and Experience • Active RN license in California is mandatory. • Bachelor's Degree in Nursing or higher is preferred. • Certification as a Case Manager (CCM) or currently pursuing eligibility for certification is desirable. • At least 5 years of nursing or related healthcare experience is essential. • Preferred: minimum of 3 years of experience in managed care. • Demonstrated ability to independently evaluate clinical information and develop effective care plans. • In-depth knowledge of evidence-based clinical practice guidelines for chronic conditions. • Capacity to apply professional judgment and critical thinking in determining medical necessity for delivering quality and cost-effective care. • Familiarity with Coordination of Care, Medicare regulations, prior authorization, and level of care criteria is a plus. • Proficiency in PC-based software programs, including Microsoft Office 365 (Word, Excel, Outlook, Teams).