Care Management - Nurse, Senior

Job DescriptionYour Role The Care Management team performs and care 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 Care Management - Nurse, Senior will report to the Manager, Care Management. In this role you will provide case management services for members with oncology diagnoses and other complex, chronic conditions. You will also apply required oncology nursing experience to determine, develop, and implement individualized plans of care based on accurate assessment of the member and current or proposed treatment plans. This role includes management of cases related to member inquiry, triage hub, chronic conditions, polypharmacy, prenatal care, voluntary member health assessments, multiple monthly ER visits, and oncology related treatment planning, symptom management, care coordination, and transitions of care across the continuum. 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. ResponsibilitiesYour Work In this role, you will: 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 Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental cases Develop appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access, and cost-effective outcomes Assess and re-evaluate health and progress due to the dynamic nature of the plan of care required on an ongoing basis Initiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settings Design appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomes Adjust plans or create contingency plans as necessary Assess members health behaviors, cultural influences and clients belief/value system Evaluate all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriers Research opportunities for improvement in assessment methodology and actively promote continuous improvement Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSC QualificationsYour Knowledge and Experience Requires a current/active unrestricted CA RN License. If assigned to another state, must maintain 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 a Certified Case Manager (CCM) certification; or obtained within 18 months of hire Requires 5 years experience in nursing, healthcare or related field. Managed care experience of 3 years is preferred Oncology nursing experience (including oncology case management, infusion services, or acute oncology care) of 3 years is preferred Bachelor of Science in Nursing or advanced degree is preferred 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 Ability to incorporate 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 is preferred Ability 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. About the Team About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us! Our Values: Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Please click here for further physical requirement detail. Equal Employment Opportunity: 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.

Created: 2026-03-15