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 Sr Manager, Care Management- Behavioral Health. 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, Behavioral Health condition, chronic conditions, poly-pharmacy, and inpatient discharge planning.

Your Knowledge and Experience

• Bachelor's degree of Science in Nursing or advanced degree is preferred
• Requires a current CA RN License
• Requires current Certified Case Manager (CCM) certification or is in process of completing certification when eligible based on CCM application requirements
• Requires 5 years of experience in nursing, healthcare, or related field
• Managed care experience of at least 3 years is preferred
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning is preferred
• Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions is preferred
• Ability to incorporate professional judgment and critical thinking when determining medical necessity that promotes quality, cost-effective care is preferred
• Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care, and length of stay criteria is preferred
• Ability to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook, and Teams is preferred