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 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

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