RN I-Medicaid, Care, Case and Disease Management ID-10214

November 23, 2024

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.

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Responsibilities:

Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.

Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.

Coordinates and assists in implementation of plan for members.

Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.

Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

Encourages member participation and compliance in the case/disease management program efforts.

Documents accurately and comprehensively based on the standards of practice and current organization policies.

Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.

Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

Completes other assigned functions as requested by management.

Disclaimer:

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

High School Diploma/GED required

Bachelor degree preferred or relevant experience in lieu of degree

Requires a minimum of two (2) years clinical experience.

Active Unrestricted NJ RN License or active Compact License Required.

Knowledge:

Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook) prefers knowledge in the use of intranet and internet applications.

Prefers working knowledge of case/care management principles.

Prefers working knowledge of principles of utilization management.

Prefers basic knowledge of health care contracts and benefit eligibility requirements.

Prefers knowledge of hospital structures and payment systems.

Skills and Abilities:

Analytical

Compassion

Interpersonal & Client Relationship Skills

Judgment

Listening

Planning/Priority Setting

Problem Solving

Team Player

Time Management

Written/Oral Communication & Organizational Skills

Salary Range:

$68,500 - $91,665

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

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