RN I, PCA/MDC/DSNP (Field-Based - Hudson County)

100 Horizon Healthcare Services, Inc; Newark (NJ); On-site; 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 a field-based RN to perform assessments for PCA and MDC services, ensuring medically appropriate care and proper authorization.

You will collaborate with patients, families, physicians, and hospitals, coordinate services across the continuum of care, and document in line with organizational policies. A NJ RN license is required; travel daily within New Jersey is expected.

Qualifications

• High School Diploma or GED required; Bachelor's degree preferred.
• Active NJ RN license required.
• Experience with case/care management and utilization management is preferred.
• Proficiency with Windows, MS Office; Lotus Notes experience preferred.

Responsibilities

• Assess clinical need against guidelines to ensure medically appropriate services.
• Coordinate with patient, family, physician, hospital and external parties.
• Monitor care and outcomes for appropriateness and effectiveness.
• Complete NJ Choice Home Care Assessments for new referrals to MLTSS.
• Support MLTSS Care Management as needed.

Skills

Analytical

Compassionate

Interpersonal skills

Bi-lingual preferred

Education

High School Diploma/GED

Bachelor's degree preferred

Tools

MS Office

Lotus Notes

Job description

About the Role

This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.

• Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.
• Evaluates the necessity, appropriateness and efficiency of service provided.
• Develops, coordinates and assists in implementation of services to meet the needs of the members.
• Coordinates with patient, 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.
• Monitors patient'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.
• Refers members to MLTSS when appropriate.
• Educates members on the availability of SNP if appropriate.
• 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.
• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Completes other assigned functions as requested by management.
• Performs duties as assigned by management.
• Completes NJ Choice Home Care Assessments for new referrals to MLTSS.
• Assists with MLTSS Case Management when necessary, to cover for FMLA or to maintain MLTSS Caseloads below contractual obligations.
• Provide support when needed to MLTSS Care Management Staff, including but not limited to Annual Assessment, 90 day and/or Post Hospital visits.

What You Bring

• Education/Experience: High School Diploma/GED required. Bachelor degree preferred or relevant experience in lieu of degree. A minimum of two (2) years clinical experience is preferred.
• Additional licensing, certifications, registrations: Active Unrestricted NJ RN License Required.
• Knowledge: Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications. Working knowledge of case/care management principles. Working knowledge of principles of utilization management. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems.
• Skills and Abilities: Analytical Compassionate Interpersonal & Client Relationship Building Skills Sound Decision Making Active Listening Organization/Planning/Priority Setting Problem Solving/Critical Thinking Team Player Time Management Written/Oral Communication Skills (Bi-lingual preferred)

Travel (If Applicable)

This is a field based position, daily local travel is required. Requires a car with valid New Jersey State License and Insurance.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too.

Salary Range

Salary Range: $70,500 - $94,395

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

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 or protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

About Us

We are the leading health insurer in New Jersey, trusted by generations of families and businesses.

We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.

Our Mission

We empower our members to achieve their best health.

Our Vision

We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.