Care Management Nurse Senior

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. 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.
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.
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
Coordinate discharge planning activities for complex and high-risk cases
Determine appropriateness of referrals to care management and specialty programs
Collaborate with providers, medical directors, and interdisciplinary teams to support member treatment plans and care continuity
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
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
• Ability to independently assess, evaluate, and interpret complex clinical information and care plans
• 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

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.
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; and Stellarus, a company designed to scale healthcare solutions. 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. News Best Company to work for, a Deloitte U.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!

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. 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.

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: 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.