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Rn I Jobs

Company

Horizon Blue Cross Blue Shield of New Jersey
Address , Newark, 07105, Nj
Employment type FULL_TIME
Salary
Expires 2023-07-19
Posted at 1 year ago
Job Description
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.
Responsibilities:
  • 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.
  • Documents accurately and comprehensively based on the standards of practice and current organization policies.
  • 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.
  • Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
  • Coordinates and assists in implementation of plan for members.
  • Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
  • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
  • Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
  • Completes other assigned functions as requested by management.
  • Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
  • 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.
  • 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.

Education/Experience:
  • Requires an associate-s or bachelor-s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
  • Requires a minimum of two (2) years clinical experience.
Utilization Management Only
  • RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.
Additional licensing, certifications, registrations:
  • Active Unrestricted NJ RN License Required

Knowledge:
  • Prefers knowledge of hospital structures and payment systems.
  • Prefers basic knowledge of health care contracts and benefit eligibility requirements.
  • 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 principles of utilization management.
  • Prefers working knowledge of case/care management principles.

Skills and Abilities:
  • Written/Oral Communication & Organizational Skills
  • Analytical
  • Compassion
  • Listening
  • Judgment
  • Problem Solving
  • Planning/Priority Setting
  • Team Player
  • Time Management
  • Interpersonal & Client Relationship Skills

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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.