RN II

Horizon Blue Cross Blue Shield Of New Jersey 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. 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. Responsibilities: Assess 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. 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. Education/Experience: 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. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or active Compact License Required. 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). 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. 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 Salary Range: $77,900 - $104,370 Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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 Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. 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.