Pediatric Case Management RN - Care Continuum Leader

Horizon Blue Cross Blue Shield; Northern (KY); Hybrid; USD 71,000 - 94,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an RN Case Manager to perform clinical duties within established guidelines and plan the continuum of care for members. The role emphasizes utilization management, care coordination, and advocacy across settings to ensure appropriate, cost-effective care.

You will assess clinical needs, coordinate services, monitor outcomes, and collaborate with patients, families, providers, and facilities.

Qualifications

• Requires an Associate 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.
• Active Unrestricted NJ RN License Required.

Responsibilities

• Assess patient's clinical need against established guidelines to ensure appropriate level of care and length of stay for inpatient stay.
• Evaluate the necessity, appropriateness and efficiency of medical services and procedures.
• Coordinate and assist in implementation of plan for members.
• Monitor and coordinate services rendered outside of the network and negotiate fees as appropriate.
• Coordinate with patient, family, physician, hospital and external customers regarding appropriateness of care.
• Deliver high quality, cost-effective care supported by clinical guidelines across the continuum of care.
• Monitor patient’s medical care activities and outcomes for appropriateness and effectiveness.
• Advocate for member/family among sites to coordinate resource utilization and evaluation of services.
• Encourage member participation and compliance in case/disease management programs.
• Document accurately based on standards of practice.
• Interact with multidisciplinary teams to ensure continuity and efficiency in care management.

Skills

Analytical

Compassion

Interpersonal & Client Relationship

Judgment

Listening

Planning/Priority Setting

Problem Solving

Team Player

Time Management

Written/Oral Communication & Organis

Education

Associates or Bachelors in Nursing

Minimum 2 years clinical experience

Active NJ RN License

Tools

MS Office (Word, Excel, PowerPoint, Outlook)

Intranet/Internet applications

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an RN Case Manager to perform clinical duties within established guidelines and plan the continuum of care for members. The role emphasizes utilization management, care coordination, and advocacy across settings to ensure appropriate, cost-effective care.

You will assess clinical needs, coordinate services, monitor outcomes, and collaborate with patients, families, providers, and facilities.