Case Management - Nurse, Senior

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.

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.