Case Manager 9/20/2017

Blue Shield of CA San Francisco, CA

San Francisco, CA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Mid-Career (2 - 15 years)
Bachelors Degree


Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of Californias Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.

We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.

Join Blue Shield in our collaboration with Collective Health, an innovative technology company founded in 2013. San Francisco based Collective Health is working to create the healthcare experience we all deserve, by harnessing the power of design and technology to improve the experience for members.

This position is primarily located in the Collective Health office in San Francisco, and offers perks such as free breakfast, catered lunches, and fully stocked snack and beverage bar. This position is primarily Monday through Friday with day and some evening hours. The Care Management RN will be co-located with Collective Healths member advocacy unit (concierge customer service) and work closely in a team model with the Collective Health member advocates, Collective Health licensed clinical social workers, and their Blue Shield team to assist members. The Care Management RN will participate in Blue Shield team meetings and Blue Shield performance evaluation, and will be expected to attend meetings at Blue Shield locations as requested.

The Care Management RN will provide outpatient telephonic case management for high risk members with complex medical needs. Case management includes assessment, advocacy, education, resource management and care coordination that promotes self-management and quality and cost-effective interventions at the right time and place.


* Determine, develop, implement, and update plan of care based on accurate and comprehensive assessment of the member and current or proposed treatment plan.

* Work collaboratively with Collective Healths team of Social Workers and interdisciplinary team to provide comprehensive case management and exceptional member experience.

* Apply detailed knowledge of Blue Shield of California (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.

* Implement transition management activities for medically complex/ high risk cases in collaboration with Utilization Management Nurse. Conducts pre/ post hospital discharge calls.

* Facilitate benefit related discussion with employer groups when needed.

* Anticipate potential barriers while establishing realistic measurable member centered goals and objectives and provide appropriate alternatives. Actively solicit member and family involvement to encourage towards goal completion.

* Participate in patient rounds, data and quality reporting.


* Current unrestricted CA RN License and ability to obtain out of state licensure as required

* BSN degree/advanced degree preferred

* Certified Case Manager (CCM) preferred, or obtain within 2 years of hire

* Requires moderate to extensive experience in nursing, health care or related field, with minimum of 5 years experience, and 2 years managed care experience preferred, including oncology, chronic conditions, heart disease, diabetes, musculoskeletal, behavioral health condition management.

* Experience working in a telephonic or outpatient environment preferred, must have excellent customer service skills

* Health coaching and motivational interviewing preferred

* Energetic, eager, and nimble

* Demonstrated ability to independently assess, evaluate, and interpret clinical information

* In depth understanding of community resources, treatment options, home health, funding sources and special programs

* Extensive knowledge of evidenced based clinical practice guidelines particularly for chronic conditions

* Incorporates professional judgment, problem solving skills and critical thinking when determining medical necessity that promotes quality, cost-effective care

* Working knowledge of regulatory and accreditation standards preferred

* Strong clinical documentation skills, independent problem identification and resolution skills

* Strong verbal, written communication and negotiation skills, ability to collaborate with Collective Healths social worker and member advocate team to support members clinical needs

* Ability to work on projects with minimal supervision

* Demonstrate cultural competence to work effectively, respectfully, and sensitively within the clients cultural context

* Advocates understanding and respect for the beliefs, value system, and decisions of the client

* Recognize the members right to self-determination as it relates to the ethical principle of autonomy

* Able to operate PC-based software programs including proficiency in Word and Excel

This position is located in San Francisco at Collective Healths office and reports to a Blue Shield manager located in Rancho Cordova.