Care Management - Nurse, Senior

Care Management Team MemberThe 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. This position also requires ongoing reassessment of care plans, awareness of healthcare trends and clinical guidelines, and the ability to participate in a rotating evening and weekend on-call schedule.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.ResponsibilitiesIn this role, you will:Work with minimal supervision to manage complex care management casesApply advanced clinical judgment to assess medical necessity and appropriateness of careDesign and implement treatment and care plans that promote quality, cost?effective outcomes aligned with benefit and contract requirementsCoordinate discharge planning activities for complex and high?risk casesDetermine appropriateness of referrals to care management and specialty programsCollaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuityEvaluate member health behaviors, cultural influences, and belief systems to identify barriers to careContribute clinical input to medical directors and support informed decision makingContinuously improve outcomes by anticipating barriers and adjusting plans of care based on reassessment, clinical changes, and guideline updatesMaintain current knowledge of healthcare service trends, regulations, and clinical practice guidelinesAbility to work evenings and weekends as part of rotating on-call schedulePerform other duties as assignedQualificationsYour Knowledge and Experience:Associate Degree in Nursing required or master's degree in relevant field for non-RN licensure.Bachelor of Science in Nursing is preferred5 years of experience in nursing, healthcare, or a related clinical field3 years of managed care experience preferredCertified Case Manager (CCM) is preferredAbility to independently assess, evaluate, and interpret complex clinical information and care plansAdvanced knowledge of evidence based clinical practice guidelines, particularly for chronic conditionsDemonstrated competence in care management functions and standards of practiceKnowledge of community resources, treatment options, home health services, funding sources, and specialty programsWorking knowledge of regulatory and accreditation standards including CMS, DHCS, URAC, NCQA, DMHC, MHPAEA, and CA SB 855 is preferredKnowledge of coordination of care, government and commercial regulations, prior authorization processes, and level of care and length of stay criteria is preferredHybrid Virtual WorkThis role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.About UsAbout Blue Shield of CaliforniaAs 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 ModelWe 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.