RN II/ONCOLOGY CASE MANAGER (REMOTE)

Horizon Blue Cross Blue Shield; New Jersey; Hybrid; USD 79,000 - 106,000; Full time

Benefits offered by this job

Salary range plus benefits

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced RN to perform case management duties using established guidelines and to plan the continuum of care for members. The role includes mentoring staff, acting as a subject matter expert, and participating in projects and committees to improve outcomes.

The position requires clinical experience, a valid NJ RN license or compact license, and payer experience.

Qualifications

• Active NJ RN license or compact license required.
• Minimum of two (2) years clinical experience.
• Minimum of two (2) years’ health care payer experience.
• CCM certification preferred.
• RN’s required to work weekends and holidays to meet regulatory standards.

Responsibilities

• Assess patient clinical need to ensure inpatient level of care is appropriate.
• Evaluate necessity and efficiency of medical services and procedures.
• Coordinate and assist in plan for members’ care.
• Monitor services outside network and negotiate fees as appropriate.
• Coordinate with patient, family, physician, hospital and other external customers.
• Advocate for members and coordinate care across the continuum of care.
• Mentor/trainer to new RN staff and act as SME for projects.
• Represent clinical teams in committee meetings and present reports.
• Contribute to quality improvement and outcomes evaluation.

Skills

RN license

Utilization management

Case management

Communication skills

Motivational interviewing

Education

High School Diploma

Bachelor's degree preferred

Tools

MS Office

Job description

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.

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. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.

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.
• 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.

Addendum for Horizon Clinical Advocate Roles

• Outreaches to members identified by Horizon as needing Clinical Advocate services.
• Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast‑paced environment.
• Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques.
• Becomes knowledgeable in ASO client employer‑sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.
• Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well‑being physical, mental, and emotional.

Schedule: 8‑ or 10‑hour workday Monday through Friday varying between 8am and 11pm.

What You Bring

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires a minimum of two (2) years clinical experience.
• Requires minimum of two (2) years’ experience with health care payer experience.
• Utilization Management Only(Utilization Inpatient Case Management does NOT apply to RN II role within HCS) : RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards.
• Requirements may vary based on department’s business needs.
• Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or active Compact License Required.
• Addendum for Horizon Clinical Advocate roles: CCM certification preferred.

Knowledge

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook).
• Should be knowledgeable in the use of intranet and internet applications.
• Requires knowledge of hospital structures and payment systems.
• Requires working knowledge of case/care/disease management principles.
• Requires working knowledge of operations of utilization, case and/or disease management processes.
• Requires knowledge of health care contracts and benefit eligibility requirements.
• Requires mentoring knowledge on the operations of utilization/case/disease management.
• Addendum for Horizon Clinical Advocate roles: Requires ability to be an empathetic critical thinker.
• Requires excellent communication and organizational skills and a high tolerance for ambiguity.
• Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization.
• Experience in active listening and motivational interviewing strongly preferred.
• Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills.
• Requires exceptional multi‑channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion.

Skills and Abilities

Adaptability/Flexibility Analytical Compassion Interpersonal & Client Relationship Skills Information/Knowledge Sharing Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills

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

Salary Range

Salary Range: $79,100 - $105,945

• 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.

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.