RN Care Manager & Member Advocate

Horizon Blue Cross Blue Shield; New Jersey; On-site; USD 79,000 - 106,000; 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 seeks an experienced RN to plan and coordinate care across the continuum, mentoring staff and serving as a subject matter expert for clinical projects.

You will collaborate with members, families, physicians, and providers to ensure appropriate, high-quality care per guidelines, with emphasis on payer operations and cost-effective outcomes. Strong MS Office skills and an active NJ RN license are required.

Qualifications

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires a minimum of two (2) years clinical experience.
• Requires minimum of two (2) years’ experience with health care payer experience.
• Active NJ RN License or Compact License required.
• CCM certification preferred for Horizon Clinical Advocate roles.
• Proficient with personal computers and MS Office (Word, Excel, PowerPoint, Outlook).
• Knowledgeable in intranet and internet applications.
• Knowledge of hospital structures and payment systems.
• Knowledge of case/care/disease management principles.
• Knowledge of utilization, case and/or disease management operations.
• Knowledge of health care contracts and benefit eligibility.
• Mentoring knowledge on utilization/case/disease management operations.

Responsibilities

• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services rendered outside the network and negotiates fees when needed.
• Coordinates with members, families, physicians, and hospitals regarding care from diagnosis to outcome.
• Delivers high-quality, cost-effective care per clinical guidelines across the continuum of care.
• Monitors care activities and evaluates outcomes for appropriateness and effectiveness.
• Advocates for members and families across settings to optimize resource use.
• Encourages member participation in case management programs.
• Documents accurately according to standards and policies.
• Interacts with multidisciplinary teams to ensure continuity and efficiency of care.

Skills

Adaptability/Flexibility

Analytical

Compassion

Interpersonal & Client Relationship

Information/Knowledge Sharing

Judgment

Listening

Planning/Priority Setting

Problem Solving

Team Player

Time Management

Written/Oral Communication

Education

High School Diploma/GED

Bachelor's degree preferred

Tools

MS Office

Intranet/Internet applications

Job description

Horizon Blue Cross Blue Shield of New Jersey seeks an experienced RN to plan and coordinate care across the continuum, mentoring staff and serving as a subject matter expert for clinical projects.

You will collaborate with members, families, physicians, and providers to ensure appropriate, high-quality care per guidelines, with emphasis on payer operations and cost-effective outcomes. Strong MS Office skills and an active NJ RN license are required.