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.
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.
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.
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.
Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; 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.
Prefers bilingual Spanish/English language skills.
Interpersonal & Client Relationship Skills
Written/Oral Communication & Organizational Skills
Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR
Requires a minimum of two (2) years clinical experience.
As New Jersey's largest health insurer, Horizon Blue Cross Blue Shield of New Jersey understands that good business starts with our employees. That's why we give our employees the resources and flexibility to succeed both professionally and personally.
Making a Difference
When you join Horizon BCBSNJ, you'll be part of a $10 billion company, serving over 3.8 million members. We work collaborat...ively with health care professionals and hospitals across the state.
You'll be at the forefront of groundbreaking changes that affect the way health care coverage is delivered to all of New Jersey's residents, including creating new products, delivery channels and consumer connection programs. For example, our new retail center demonstrates how we're leading the way for our community to have a more personal, better health insurance experience. This retail center will bring our customers convenient, face-to-face interaction and support.