Care Management - Nurse, Senior (CA Children's Services)

Role Summary The Children’s Services Program (CSP) team provides identification, referrals, and care management for all Medi‑Cal members under 21 years old and collaborates within Promise Clinical Team. The Case Management Nurse, Senior will report to the CSP Manager. In this role you will be Perform clinical review, assessment, evaluation of medical services for the organization using the established and approved Blue Shield Medical Policies and California Children’s Services (CCS), Early Intervention‑Early Start (EIES), Developmental Disability Services (DDS), Children with Special Healthcare Needs (CSHCN), Early Periodic Screening Diagnostic Treatment (EPSDT) services Eligibility guideline which align with nationally recognized standards. Responsible for managing member needs for specific CCS/EIES/DDS/CSHCN/EPSDT and other clinical programs and care coordination. Responsible in assisting and working daily inventory, providing high‑quality clinical reviews, performing efficient care management and care coordination, and ensuring compliance performance metrics are met. Responsibilities Perform complex care management/care management/care coordination for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medi‑Cal and CCS/EIES/DDS/CSHCN/EPSDT Eligibility guidelines. Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance with state, federal and accreditation requirements Develop and review member centered care plans and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate Prepares and presents cases to Medical Director (MD) for medical director oversight and CCS eligibility determination. Communicate determinations to providers and/or members to in compliance with state, federal, and accreditation requirements. Identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate and provide care coordination to identified CSP members. Provide referrals to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary. In addition to collaboration with County CCS and Regional Center Qualifications Requires a current CA RN License. Bachelor of Science in Nursing or advanced degree preferred. Certified Case Manager (CCM) through the Commission for Case Manager Certification or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field is preferred Requires at least 5 years of prior relevant experience including 4 years’ experience in Medi‑Cal Clinical Review, Case Management and Care Coordination preferred 2 years’ experience in Pediatrics with Children's Health Programs (EI, ES, DDS, EPSDT, CHDP) specifically California Children’s Services (CCS) preferred Working knowledge of regulatory and accreditation standards (URAC, NCQA, DMHC, Case Management Society of America CMSA) preferred Care Coordination and Case Management experience strongly preferred Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need. 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 Information Job Identification: 20261059 Job Category: Healthcare Services and Operations Posting Date: 2026-06-17T20:04:41+00:00 Job Schedule: Full time Locations: Long Beach, CA, United States Locations: CA, United States Locations: El Dorado Hills, CA, United States Locations: Lodi, CA, United States Locations: Oakland, CA, United States Locations: Rancho Cordova, CA, United States Locations: Redding, CA, United States Locations: San Diego, CA, United States Locations: Woodland Hills, CA, United States Pay Range for California: $90860.00 to $136290.00 Pay Range for Bay Area: $102424.00 to $153636.00 Role can be filled by a candidate requiring sponsorship: No #J-18808-Ljbffr Blue Shield of California