RN I-Pediatric Case Management

Horizon Blue Cross Blue Shield; Northern (KY); Hybrid; 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 an RN Case Manager to perform clinical duties within established guidelines and plan the continuum of care for members. The role emphasizes utilization management, care coordination, and advocacy across settings to ensure appropriate, cost-effective care.

You will assess clinical needs, coordinate services, monitor outcomes, and collaborate with patients, families, providers, and facilities.

Qualifications

• Requires an Associate 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.
• Active Unrestricted NJ RN License Required.

Responsibilities

• Assess patient's clinical need against established guidelines to ensure appropriate level of care and length of stay for inpatient stay.
• Evaluate the necessity, appropriateness and efficiency of medical services and procedures.
• Coordinate and assist in implementation of plan for members.
• Monitor and coordinate services rendered outside of the network and negotiate fees as appropriate.
• Coordinate with patient, family, physician, hospital and external customers regarding appropriateness of care.
• Deliver high quality, cost-effective care supported by clinical guidelines across the continuum of care.
• Monitor patient’s medical care activities and outcomes for appropriateness and effectiveness.
• Advocate for member/family among sites to coordinate resource utilization and evaluation of services.
• Encourage member participation and compliance in case/disease management programs.
• Document accurately based on standards of practice.
• Interact with multidisciplinary teams to ensure continuity and efficiency in care management.

Skills

Analytical

Compassion

Interpersonal & Client Relationship

Judgment

Listening

Planning/Priority Setting

Problem Solving

Team Player

Time Management

Written/Oral Communication & Organis

Education

Associates or Bachelors in Nursing

Minimum 2 years clinical experience

Active NJ RN License

Tools

MS Office (Word, Excel, PowerPoint, Outlook)

Intranet/Internet applications

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 SkillsAt 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. If you are passionate about making an impact, we'd love to hear from you!**Salary Range:**$70,500 - $94,395This 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.**Horizon Blue Cross Blue Shield of New Jersey** empowers our members to achieve their best health. For over **90 years**, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the **3.5 million** people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.**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.