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Clinical Care Manager

2 months ago

Hopewell, New Jersey, United States Blue Cross and Blue Shield Association Full time
Job Summary

This field-based position is responsible for performing assessments of members using established guidelines to ensure appropriate levels of care and develop a member-centric plan of care.

Key Responsibilities
  • Assesses member's clinical needs against established guidelines and/or standards to ensure that the services provided are medically appropriate to members' needs.
  • Evaluates the necessity, appropriateness, and efficiency of services provided.
  • Develops, coordinates, and assists in the implementation of members' individualized plans of care.
  • Coordinates with patients, families, physicians, hospitals, 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 members' 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 program.
  • 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.
Requirements
  • High School Diploma/GED required
  • Bachelor's degree preferred or relevant experience in lieu of degree
  • Requires a minimum of two (2) years of clinical experience.
Additional Requirements
  • Active Unrestricted NJ RN License Required
Preferred Qualifications
  • Proficiency in the use of personal computers and supporting software in a Windows-based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
  • Working knowledge of case/care management principles.
  • Working knowledge of principles of utilization management.
  • Prefers basic knowledge of healthcare contracts and benefit eligibility requirements.
  • Prefers knowledge of hospital structures and payment systems.
Skills and Abilities
  • Analytical
  • Compassionate
  • Interpersonal & Client Relationship Building Skills
  • Sound Decision Making
  • Active Listening
  • Organization/Planning/Priority Setting
  • Problem Solving/Critical Thinking
  • Team Player
  • Time Management
  • Written/Oral Communication Skills (Bi-lingual preferred)
Travel Requirements
  • This is a field-based position, daily local travel is required.
  • Requires a car with valid New Jersey State License and Insurance.
Compensation and Benefits
  • 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.
  • Comprehensive health benefits (Medical/Dental/Vision)
  • Retirement Plans
  • Generous PTO
  • Incentive Plans
  • Wellness Programs
  • Paid Volunteer Time Off
  • Tuition Reimbursement