Job Description
Job Description Your Role The Children's Services Program (CSP) team provides identification, referrals, and care management for all Medi-Cal members under 21 years old and collaborates within Promise Clinical Team. The Case Management Nurse, Senior will report to the CSP Manager. In this role you will be Perform clinical review, assessment, evaluation of medical services for the organization using the established and approved Blue Shield Medical Policies and California Children's Services (CCS), Early Intervention-Early Start (EIES), Developmental Disability Services (DDS), Children with Special Healthcare Needs (CSHCN), Early Periodic Screening Diagnostic Treatment (EPSDT) services Eligibility guideline which align with nationally recognized standards. Responsible for managing member needs for specific CCS/EIES/DDS/CSHCN/EPSDT and other clinical programs and care coordination. Responsible in assisting and working daily inventory, providing high-quality clinical reviews, performing efficient care management and care coordination, and ensuring compliance performance metrics are met.
Responsibilities Your Work In this role, you will:
- Perform complex care management/care management/care coordination for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medi-Cal and CCS/EIES/DDS/CSHCN/EPSDT Eligibility guidelines.
- Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance.
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
- Develop and review member centered care plans and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.
- Prepares and presents cases to Medical Director (MD) for medical director oversight and CCS eligibility determination.
- Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.
- Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate and provide care coordination to identified CSP members.
- Provides referrals to Social Services, Behavioral Health, Appeals and Grievance, and Quality Departments as necessary. In addition to collaboration with County CCS and Regional Centers.
Qualifications Your Knowledge and Experience - Required current CA RN License. Public Health Nurse (PHN) License preferred.
- Bachelor of Science in Nursing or advanced degree preferred.
- Required Certified Case Manager (CCM) through the Commission for Case Manager Certification or is in process of completing certification when eligible based on CCM application requirements or National Certification in related field.
- Requires at least 5 years of prior relevant experience.
- 4 years' experience in Medi-Cal Clinical Review, Case Management and Care Coordination preferred.
- 2 years' experience in Pediatrics with Children's Health Programs (EI, ES, DDS, EPSDT, CHDP) specifically California Children's Services (CCS) preferred.
- Working knowledge of regulatory and accreditation standards (URAC, NCQA, DMHC, Case Management Society of America CMSA) preferred.
- Required Care Coordination and Case Management experience.
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: At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.
Two Ways of Working:
- Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
o Member-facing and approved out-of-state roles remain remote.
o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
o 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.
- On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
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.
Job Tags
Full time, Contract work, Part time, Work at office, Local area, Remote work, Work from home, Home office, 1 day per week,