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Company

Horizon Blue Cross Blue Shield of New Jersey
Address , Wall, Nj
Employment type PART_TIME
Salary $75,300 - $100,800 a year
Expires 2023-06-26
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. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.
Responsibilities:
  • 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.
  • May assume leadership type activities in team leads absence.
  • Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
  • Present reports required at committee meetings.
  • Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
  • 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.
  • Serves as mentor/trainer to new RN's and other staff as needed.
  • Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
  • Encourages member participation and compliance in the case/disease management program efforts.
  • Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
  • Subject matter expert for user acceptance testing for medical management system.
  • 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.
  • 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.
  • Represent clinical teams within committee meetings
  • Acts as subject matter expert for respective area for projects.
  • Documents accurately and comprehensively based on the standards of practice and current organization policies.
  • Coordinates and assists in implementation of plan for members.
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.
  • Requires minimum of two (2) years’ experience with health care payer 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 or active Compact License Required.

Knowledge:
  • Requires working knowledge of operations of utilization, case and/or disease management processes.
  • Requires mentoring knowledge on the operations of utilization/case/disease management.
  • Requires working knowledge of case/care/disease management principles.
  • Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications.
  • Requires knowledge of hospital structures and payment systems.
  • Requires knowledge of health care contracts and benefit eligibility requirements.

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

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.
Salary Range:
$75,300 - $100,800
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:
  • Retirement Plans
  • Tuition Reimbursement
  • Comprehensive health benefits (Medical/Dental/Vision)
  • Incentive Plans
  • Wellness Programs
  • Paid Volunteer Time Off
  • Generous PTO
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.