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, poly-pharmacy, 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 current and valid CA RN License or valid RN license(s) from other state(s). Preferred licensure from a compact state. If assigned to another state, must maintain an active, unrestricted RN license in assigned state(s) or the ability to obtain required RN license (in addition to primary state license) within 90 days of hire
- Requires an Associate's Degree in Nursing
- 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
- Prior transplant experience is required
- Desired 3 years of managed care experience
- 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
- 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
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.