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Case Management - Nurse, Senior

  • Job
    Senior Level
  • Healthcare
  • $87.2K - $130.9K
  • San Diego, +2

AI generated summary

  • You need CA RN license, CCM certification or in process, 5+ years exp. in nursing/healthcare, 3+ years managed care exp., transitions of care exp., excellent communication skills.
  • You will research, design, and implement individualized care plans, assess members' health needs, manage transitions of care, and collaborate with providers for quality, cost-effective outcomes.


  • Current CA RN License. Bachelors 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


  • 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.


What qualifications are required for the Senior Care Manager position?

The qualifications required for the Senior Care Manager position include a current CA RN License, a Bachelor's of Science in Nursing or advanced degree (preferred), Certified Case Manager (CCM) Certification or in progress of completing certification, 5+ years of experience in nursing, health care, or a related field, 3+ years of managed care experience, transitions of care experience (preferred), and excellent communication skills.

What are the primary responsibilities of a Senior Care Manager?

The primary responsibilities of a Senior Care Manager include researching and designing treatment/care plans, initiating timely individualized care plans, determining the appropriateness of referrals for CM services, providing referrals to Quality Management, Disease Management, and Appeals and Grievance departments, managing member treatment to meet recommended length of stay, assessing member health behaviors and values, developing appropriate and fiscally responsible plans of care, and implementing and modifying plans of care based on ongoing assessment.

Is previous experience in health insurance/managed care required for this role?

While health insurance/managed care experience is desired, it is not a strict requirement for the Senior Care Manager position.

What certifications are beneficial for a Senior Care Manager?

A Certified Case Manager (CCM) Certification is beneficial for a Senior Care Manager, and candidates are encouraged to pursue this certification if not already obtained.

Who does the Senior Care Manager report to?

The Senior Care Manager reports to the Manager of Care Management.

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Blue Shield of California strives to create a healthcare system worthy of its family and friends that is sustainably affordable. Blue Shield of California is a tax-paying, nonprofit, independent member of the Blue Shield Association with 4.7 million members, 7,800 employees, and $22.9 billion in annual revenue. Founded in 1939 in San Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare healthcare service plans in California. Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.