RN II Oncology Care Navigator

Horizon Blue Cross Blue Shield of New Jersey; United States; Remote; USD 79,000 - 106,000; Full time

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced RN for clinical advocacy and care management. In this role you apply guidelines to determine appropriate inpatient levels, coordinate the continuum of care, and mentor other staff while leading key projects.

You will assess care needs, advocate for members across networks, and ensure high-quality, cost-effective services. A NJ RN license and payer experience are required.

Qualifications

• Minimum of two years clinical experience.
• Minimum of two years’ experience with health care payer experience.
• Active NJ RN License or Active Compact License required.
• CCM certification preferred.

Responsibilities

• Assesses patient’s clinical need against established guidelines to ensure appropriate level of care.
• 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 negotiates fees for such services as appropriate.
• 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.
• Serves as mentor/trainer to new RN’s and other staff as needed.
• Acts as subject matter expert for respective area for projects.
• May assume leadership type activities in team leads absence.
• Represent clinical teams within committee meetings
• Present reports required at committee meetings.
• Subject matter expert for user acceptance testing for medical management system.

Skills

Clinical experience

Health care payer experience

Motivational interviewing

Mentoring

Education

RN license

Bachelor degree preferred

High School Diploma/GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced RN for clinical advocacy and care management. In this role you apply guidelines to determine appropriate inpatient levels, coordinate the continuum of care, and mentor other staff while leading key projects.

You will assess care needs, advocate for members across networks, and ensure high-quality, cost-effective services. A NJ RN license and payer experience are required.