Case Management - Nurse, Senior

Your Role

The Case Management team performs and 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, poly-pharmacy, pre-natal care, and voluntary member health assessment, in addition to indication of multiple monthly ER visits.

Your Knowledge and Experience

• Bachelor 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
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning.
• Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions.
• Incorporates 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 desirable.
• Able to operate PC-based software programs including proficiency in Microsoft Office 365 applications including Word, Excel, Outlook and Teams.