Care Management - Nurse, Senior

Your 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.

Your 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.