Care Management - Nurse, Senior (DSNP)

Case Management Nurse, Senior

The Care Management team coordinates, educates, and advocates care for the Dual-Special Needs (DSNP) population with Blue Shield of California. The Case Management Nurse, Senior will report to the Manager of Care Management within Medical Care Solutions. In this role you will be responsible for managing a caseload of DSNP members, reviewing Health Risk Assessments and completing Individualized Care Plans, engaging members to reduce readmissions to the hospital, and supporting the DSNP care management team.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Responsibilities

In this role, you will:

• Research and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type.
• Initiate timely individualized care plans (ICP) based on health risk assessment (HRA) completion, participation in and documentation of interdisciplinary meetings (ICT), assisting in transitions of care across all ages.
• 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 members' needs and acuity
• Assess members' health behaviors, cultural influences and clients belief/value system. Evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers.
• Research opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipates potential barriers while establishing realistic goals to ensure success for the member, providers and BSC.
• Determine realistic goals and objectives and provide appropriate alternatives. Actively solicit client's involvement.
• Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes. Adjust plans or create contingency plans as necessary.
• Assess and re-evaluates health and progress due to the dynamic nature of the plan of care required on an ongoing basis. Initiates and implements appropriate modifications in plan of care to adapt to changes occurring over time and through various settings.
• Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes.
• Recognize need for contingency plans throughout the healthcare process. Develop and implement the plan of care based on accurate assessment of the members and current of proposed treatment.

Qualifications

Your Knowledge and Experience?

• Current CA RN License required
• Bachelor's of Science in Nursing or advanced degree preferred
• Certified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirements
• Requires 5+ years' experience in nursing, health care or related field.
• 3+ years managed care experience preferred. Health insurance/managed care experience desired.
• Transitions of care experience preferred
• Excellent communications skills

About Us

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model

We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:

• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Job Info

• Job Identification 20252476
• Job Category Healthcare Services and Operations
• Locations Long Beach, CA, United States CA, United States El Dorado Hills, CA, United States Lodi, CA, United States Oakland, CA, United States Rancho Cordova, CA, United States Redding, CA, United States San Diego, CA, United States Woodland Hills, CA, United States
• Pay Range for California $89100.00 to $133650.00
• Pay Range for Bay Area $100440.00 to $150660.00
• Note Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
• Role can be filled by a candidate requiring sponsorship No