Case Management - Nurse, Senior

Your Role

The Case Management team performs case management (CM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members' care including clinical nurses and treating MDs. The Case Management - Nurse, Senior will report to the Manager, Care Management. In this role you will determine, develop and implement the plan of care based on accurate assessment of the member and current or proposed treatment plan in cases of member inquiry, triage hub, chronic conditions, polypharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. 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.

Your Knowledge and Experience

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 5 years of prior experience in nursing, healthcare or related field
• Requires a Certified Case Manager (CCM) Certification or obtained within 18 months of hire
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
• Extensive knowledge of evidence based clinical practice guidelines particularly for chronic conditions
• Professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets
• Proficiency in PC-based software programs including Microsoft Office 365 applications including Word, Excel, Outlook and Teams