RN Care Navigator for PCA/MDC/SNP Plans

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (NJ); On-site; USD 71,000 - 94,000; Full time

Benefits offered by this job

Health benefits

Retirement plan

PTO

Incentive plans

Wellness programs

Volunteer time off

Tuition reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a Clinical Advocate to perform assessments for PCA/MDC services and authorize appropriate levels of care. The role emphasizes care coordination, patient advocacy, and collaboration with providers to ensure high-quality, cost-effective care across the continuum.

The ideal candidate holds an RN license with payer experience and strong knowledge of case management principles, delivering compassionate, evidence-based guidance to members and

Qualifications

• High School Diploma or GED required.
• Minimum of two (2) years of clinical nursing experience.
• Minimum of two (2) years of healthcare payer experience.
• Active, unrestricted New Jersey RN license or Compact RN license required.
• Knowledge of case management, care management, and disease management principles.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, Outlook).

Responsibilities

• Perform assessments for PCA and MDC services to determine appropriate levels of care and services to authorize.
• Evaluate necessity, appropriateness, and effectiveness of healthcare services.
• Coordinate and implement individualized care plans across the continuum of care.
• Monitor utilization and outcomes to ensure services remain appropriate and effective.
• Advocate for members to access needed healthcare services and resources.
• Collaborate with physicians, hospitals, and other stakeholders to support coordinated care.

Skills

Clinical assessment

Care coordination

Member advocacy

Critical thinking

Communication

Organization

Collaboration

Adaptability

Education

High School Diploma or GED

Bachelor's degree preferred

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a Clinical Advocate to perform assessments for PCA/MDC services and authorize appropriate levels of care. The role emphasizes care coordination, patient advocacy, and collaboration with providers to ensure high-quality, cost-effective care across the continuum.

The ideal candidate holds an RN license with payer experience and strong knowledge of case management principles, delivering compassionate, evidence-based guidance to members and