RN Care Manager: Transitional Care & High-Risk Outreach

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (AL); Remote; 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 is seeking an experienced Registered Nurse to perform care management for the Primary Nurse population. You will assess clinical needs, plan transitions of care, and develop member-centric care plans, coordinating with providers and families to ensure high-quality, cost-effective outcomes.

The role requires an RN license, a bachelor’s or associate degree, 2+ years of clinical experience, and 3+ years in the health care delivery system.

Qualifications

• 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. Experience with both acute and chronic conditions preferred.
• Requires a minimum of three (3) years' experience in the health care delivery system/industry.
• Experience with health care payer experience strongly preferred.

Responsibilities

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure.
• Facilitates response to gaps in care and identified high risk members to 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 implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness.
• Coordinates with members, 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 RN's and other staff as needed
• Presents clinical cases during audits conducted by external review organizations.

Skills

RN License

Clinical experience

Healthcare payer experience

Bi-lingual

Education

Associate's or Bachelor's degree in nursing

Accredited diploma nursing school

Tools

MS Office

Microsoft Outlook

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced Registered Nurse to perform care management for the Primary Nurse population. You will assess clinical needs, plan transitions of care, and develop member-centric care plans, coordinating with providers and families to ensure high-quality, cost-effective outcomes.

The role requires an RN license, a bachelor’s or associate degree, 2+ years of clinical experience, and 3+ years in the health care delivery system.