In this role, you will be responsible for performing RN duties for the Primary Nurse Population using established guidelines to ensure appropriate level of care, planning for the transition to the continuum of care and developing a member centric plan of care. Primary Nurses will outreach to high risk members and will work to engage members in preventative care opportunities and screenings when possible.
Assesses member's clinical needs against established guidelines and/or standards to ensure that the services provided are medically appropriate to the member's needs and aligned with the benefit structure.
Facilitates response to gaps in care and identified high risk members’ appropriate settings of care for annual wellness visits including collaboration with treating provider.
Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs.
Develops, coordinates and assists in the implementation of individualized plan of care for members and identification of barriers towards self-management and optimal wellness.
Coordinates with member, 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 including transitional care.
Monitors member'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.
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Serves as mentor/trainer to new RNs and other staff as needed.
Presents clinical cases during audits conducted by external review organizations.
Performs other duties as assigned by management.
Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook. Prefers knowledge in the use of intranet and internet applications.
Requires working knowledge of case/care/disease management principles.
Requires working knowledge of operations of utilization, case and/or disease management processes.
Requires working knowledge of principles of utilization management.
Requires basic knowledge of health care contracts and benefit eligibility requirements.
Requires knowledge of hospital structures and payment systems.
Prefers understanding of fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
Skills and Abillities:
Bi-lingual proficiency preferred.
Interpersonal & Client Relationship
Sound decision making
Organization Planning/Priority Setting
Problem Solving/Critical Thinking
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. Prefer experience with the elderly, frail and those with chronic conditions.
Requires a minimum of three (3) years' experience in the health care delivery system/industry.
Experience with health care payer strongly preferred.
Requires an active New Jersey Registered Nurse License.
Prefers pending or obtained certification in Case Management, Certified Diabetes Educator (CDE), or other applicable clinical specialties.
Requires a valid Driver's License and Insurance.
Travel (if Applicable):
Travel primarily within the State of NJ may be required. Occasional travel in the tri-state area may also be required.
The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.
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.
We offer a highly competitive salary, dynamic work environment, and a comprehensive benefits package. For immediate consideration, please apply online and reference job requisition #KM082017-10194 at: www.HorizonBlue.com/Careers.
About Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey, the only licensed Blue Cross and Blue Shield plan in New Jersey, provides health insurance coverage to more than 3.8 million people throughout all of North, Central, and South Jersey.Horizon Blue Cross Blue Shield of New Jersey is best known for our managed care and traditional indemnity plans for individuals and employers — the cornerstone of our heal...th care business.Horizon BCBSNJ traces its history back to 1932 when Associated Hospitals of Essex County, Inc. was formed as a multi-hospital prepayment plan. The company later became the nation's first Blue Cross Plan. Horizon Blue Cross Blue Shield of New Jersey is a not-for-profit, health service corporation. A 15-member Board of Directors governs the company for its members. There are no shareholders.