Case Management - Nurse, Senior
Company: Blue Shield of California
Location: Lynwood
Posted on: July 20, 2025
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Job Description:
Work Schedule M-F 8-5 with late shift of 10:30-7pm about 3x/mo
and 1 Saturday per qtr Your Role The Care Management team will
serve to support the mission of the department, which is to provide
support to patients in maintaining health and wellness in the
outpatient setting. The Senior Care Manager will report to the
Manager of Care Management. In this role you will ensure that
services are provided based on standardized procedures including
coordination of care with specialists, community resources. Care
Managers perform a blended function of utilization management (UM)
and care management (CM) activities demonstrating clinical
judgement and independent analysis, collaborating with members and
those involved with members’ care including clinical nurses and
treating physicians. Your Work 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. Initiation of 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. Determines appropriateness of referral for CM
services, mental health, and social services. Provides Referrals to
Quality Management (QM), Disease Management (DM) and Appeals and
Grievance department (AGD). Conducts member care review with
medical groups or individual providers for continuity of care, out
of area/out of network and investigational/experimental cases
Manages member treatment in order to meet recommended length of
stay. Ensures DC planning at levels of care appropriate for the
members needs and acuity. Assessment: Assesses 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 promotes continuous
improvement. Anticipates potential barriers while establishing
realistic goals to ensure success for the member, providers and
BSC. Determines realistic goals and objectives and provides
appropriate alternatives. Actively solicits client’s involvement.
Planning: Designs appropriate and fiscally responsible plan of care
with targeted interventions that enhance quality, access, and
cost-effective outcomes. Adjusts plans or creates contingency plans
as necessary. Assesses 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. Develops appropriate and fiscally responsible plan of
care with targeted interventions that enhance quality, access, and
cost-effective outcomes. Recognizes need for contingency plans
throughout the healthcare process. Develops and implements the plan
of care based on accurate assessment of the member and current of
proposed treatment. Your Knowledge and Experience Bachelors of
Science in Nursing or advanced degree preferred. Requires a current
CA RN License Certified Case Manager (CCM) Certification or is in
process of completing certification when eligible based on CCM
application requirements Requires at least 5 years of prior
experience in nursing, healthcare or related field A minimum of 3
years managed care experience in inpatient, outpatient or managed
care environment preferred Health insurance/managed care experience
preferred Transitions of care experience preferred • Excellent
communications skills
Keywords: Blue Shield of California, San Bernardino , Case Management - Nurse, Senior, Healthcare , Lynwood, California
