RN I-Pediatric Case Management

100 Horizon Healthcare Services, Inc; Hopewell (NJ); On-site; USD 71,000 - 94,000; Full time

Benefits offered by this job

Health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Paid volunteer time off

Tuition reimbursement

Job summary

Horizon BCBSNJ in New Jersey seeks an experienced RN to perform care management duties within established guidelines, planning the continuum of care for members. You will assess clinical needs, evaluate services, and coordinate plans with patients, families, and providers to ensure appropriate inpatient care.

The role requires an active NJ RN license and at least two years of clinical experience, with proficiency in MS Office and healthcare contracts knowledge.

Qualifications

• Requires an associates or bachelors 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.
• Active Unrestricted NJ RN License Required; knowledge of MS Office and basic computer skills preferred.

Responsibilities

• Assesses patient's clinical need against guidelines to ensure appropriate level of care for inpatient stay.
• Evaluates necessity, appropriateness and efficiency of medical services and procedures.
• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services outside the network and negotiates fees as appropriate.
• Coordinates with patient, family, physician, hospital and external customers regarding care.
• Delivers high quality, cost-effective care per plan across the continuum.
• Monitors medical care activities and outcomes for appropriateness and effectiveness.
• Advocates for member/family among sites to optimize resource use.
• Encourages member participation in case/disease management efforts.
• Documents accurately per standards and policies.
• Interacts with multidisciplinary teams to ensure continuity of care.
• Understands fiscal accountability and its impact on resources.
• Participates in quality improvement to enhance member outcomes.
• Completes other functions as requested by management.

Skills

Analytical

Compassion

Interpersonal & Client Relationship

Judgment

Listening

Planning/Priority Setting

Problem Solving

Team Player

Time Management

Written/Oral Communication & Organ

Education

Associates or Bachelors in nursing or health field

Tools

MS Office

Windows

Intranet/Internet apps

Job description

About the Role

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.

What You'll Do

• Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate.
• 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.
• 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.
• 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.

What You Bring

Education/Experience

Requires an associates or bachelors 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.

Active Unrestricted NJ RN License Required Knowledge: Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook) prefers knowledge in the use of intranet and internet applications. Prefers working knowledge of case/care management principles. Prefers 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 Compassion Interpersonal & Client Relationship Skills Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills

Why Horizon?

At Horizon, you will 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. If you are passionate about making an impact, we’d love to hear from you!

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.

Horizon also provides a comprehensive compensation and benefits package which includes:

• 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, 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.