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Case Manager - Nurse, Senior (HEDIS )

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

AI generated summary

  • You need a CA RN License, CCM Certification or in progress, 5+ years healthcare experience, HEDIS knowledge, PC software skills, strong communication and leadership abilities, and understanding of NCQA and regulatory requirements.
  • You will analyze HEDIS data, create education materials, develop care plans, coordinate care, provide referrals, and ensure quality healthcare outcomes as a Nurse Case Manager at Blue Shield of California.


  • Requires a current CA RN License. Bachelor 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 at least 5 years of prior experience in nursing, healthcare or related field
  • HEDIS and/or relevant Quality Improvement experience required
  • Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources
  • Able to operate PC-based software programs including proficiency in Word and Excel
  • Strong clinical documentation skills, independent problem identification and resolution skills
  • Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills
  • Competent understanding of NCQA and federal regulatory requirements
  • Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable.
  • Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
  • Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making


  • Create education materials for the HEDIS Initiatives selected and educate current staff on HEDIS measures and how to close the HEDIS Care Gaps
  • Analyze HEDIS data sets to identify members who need additional support and outreach to members to provide education and improve healthcare outcomes
  • Collaborate with quality department to determine and address gaps in care, make suggestions to Management if the HEDIS Gap Closure focus should be updated
  • Assist the FEP PPO Clinical team to meet the Blue Cross Blue Shield FEP Association requirements
  • 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
  • Provide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)
  • Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team
  • Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes
  • Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings
  • Applies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.
  • Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.
  • Coordinates Care for Lower Level of Care coordination such as Skilled Nursing Facility, Home Health, Home Infusion, Rehab, and other community program as appropriate.
  • Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).
  • Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health.
  • Must be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentation


What are the primary responsibilities of a Senior Nurse Case Manager with a focus on HEDIS?

The primary responsibilities include performing integrated case management and disease management activities, demonstrating clinical judgment and independent analysis, collaborating with members and healthcare professionals, and developing and implementing a comprehensive plan of care based on accurate assessments.

Who does the HEDIS Registered Nurse Case Manager report to?

The HEDIS Registered Nurse Case Manager reports to the FEP Department Manager.

What specific skills are required for this role?

Skills required for this role include strong clinical judgment, independent analysis, effective communication, collaboration with healthcare professionals, and the ability to develop and implement comprehensive care plans based on accurate assessments.

What is the main focus of the HEDIS Registered Nurse Case Manager's role?

The main focus of the role is to ensure high-quality care management and disease management activities for members participating in the Federal Employee Program (FEP), with a specific emphasis on HEDIS measures and compliance.

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Founded Year

Mission & Purpose

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.