RN I, PCA/MDC/SNP - Specialty Chronic Condition Plan

Horizon Blue Cross Blue Shield NJ; New Jersey; 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 candidate to perform assessments for PCA and MDC services, using established guidelines to authorize care.

The role requires RN licensure in NJ or compact, 2+ years clinical nursing and payer experience, with a bachelor’s degree preferred; CCM certification is a plus, and the position offers full-time work in Hopewell, NJ with comprehensive benefits.

Qualifications

• Minimum of two years of clinical nursing experience.
• Minimum of two years of healthcare payer experience.
• Active, unrestricted New Jersey RN license or Compact RN license.
• Certified Case Manager (CCM) certification preferred for Clinical Advocate-related assignments.
• Bachelor’s degree preferred.
• High School Diploma or GED required.

Responsibilities

• Conduct comprehensive member assessments using established guidelines and assessment tools.
• Evaluate the necessity, appropriateness, and effectiveness of healthcare services and procedures.
• Assess clinical needs and support authorization of services based on established standards.
• Monitor healthcare utilization and member outcomes to ensure services remain appropriate.
• Coordinate and assist with the implementation of individualized care plans.
• Facilitate delivery of high-quality, cost-effective care across the continuum of care.
• Advocate for members and families to ensure access to appropriate healthcare services.
• Partner with physicians, hospitals, caregivers, and multidisciplinary teams to support coordinated care delivery.
• Maintain accurate, timely, and comprehensive documentation in accordance with professional standards.
• Serve as a resource for peers and contribute to knowledge-sharing activities.

Skills

Clinical assessment

Payer experience

Assessment tools

Education

High School Diploma or GED

Bachelor’s degree preferred

Tools

Assessment tools

Job description

About This Role

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

Highlights

• Pay: $70,500 - $94,395/year
• Location: Hopewell, NJ
• Schedule: Full-time

What You'll Do

• Conduct comprehensive member assessments using established guidelines and assessment tools.
• Evaluate the necessity, appropriateness, and effectiveness of healthcare services and procedures.
• Assess clinical needs and support authorization of services based on established standards.
• Monitor healthcare utilization and member outcomes to ensure services remain appropriate.
• Coordinate and assist with the implementation of individualized care plans.
• Facilitate delivery of high-quality, cost-effective care across the continuum of care.
• Advocate for members and families to ensure access to appropriate healthcare services.
• Partner with physicians, hospitals, caregivers, and multidisciplinary teams to support coordinated care delivery.
• Maintain accurate, timely, and comprehensive documentation in accordance with professional standards.
• Serve as a resource for peers and contribute to knowledge-sharing activities.

Requirements

Education:

• High School Diploma or GED required
• Bachelor’s degree preferred

Experience:

• Minimum of two (2) years of clinical nursing experience
• Minimum of two (2) years of healthcare payer experience

Licenses & Certifications:

• Active, unrestricted New Jersey Registered Nurse (RN) license or Compact RN license required
• Certified Case Manager (CCM) certification preferred for Clinical Advocate-related assignments

Benefits

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

About Horizon Blue Cross Blue Shield NJ

Horizon Blue Cross Blue Shield of New Jersey is a leading healthcare provider committed to delivering exceptional patient care. For over 90 years, they have been New Jersey’s health solutions leader, driving innovations that improve healthcare quality and member experience.