DSNP Care Manager (Essex County)

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

7d•$63,000 - $84,420

About The Position

This field-based position is accountable for assessing and managing care for Dual Special Needs members using established guidelines to determine appropriate levels of care and develop member-centered care plans. The role provides field-based and telephonic case management, coordinates services across the healthcare continuum, advocates for members and families, and monitors care and outcomes. It also requires timely and accurate documentation and adherence to organizational policies, regulatory requirements, quality standards, and evidence-based clinical practice.

Requirements

High school diploma or GED.
At least three years of broad clinical experience.
At least three years of experience in home care, discharge planning, case management, or a related healthcare setting.
At least three years of experience working within the healthcare delivery system.
Active, unrestricted New Jersey license as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Social Worker (SW), or Certified Social Worker (CSW).
Strong knowledge of case management standards and best practices.
Strong understanding of managed care concepts and healthcare delivery systems.
Knowledge of HEDIS measures and quality improvement principles.
Strong knowledge of medical terminology.
Understanding of care coordination, resource management, and member advocacy.
Knowledge of community resources and support services available to vulnerable populations.

Nice To Haves

Bachelor’s degree in Nursing, Social Work, Healthcare, Behavioral Health, or a related field.
Experience working with elderly, frail, disabled, or complex-needs populations.
Experience supporting Medicare, Medicaid, Dual Eligible, or Special Needs Plan (SNP) populations.
Experience conducting field-based care management and home visits.
Familiarity with dual eligibility programs and government-sponsored healthcare plans.
Knowledge of population health management and chronic condition management.
Understanding of social determinants of health and their impact on healthcare outcomes.
Experience coordinating care across medical, behavioral health, and community-based services.

Responsibilities

Assess members’ clinical, functional, and psychosocial needs using established clinical guidelines and care management standards.
Evaluate the medical necessity, appropriateness, and effectiveness of services provided.
Develop, coordinate, and support implementation of individualized, member-centered care plans.
Identify healthcare needs, barriers to care, and opportunities to improve outcomes.
Coordinate care and services with members, families, physicians, hospitals, community organizations, and other healthcare providers.
Ensure care coordination across the continuum, from diagnosis through treatment and ongoing support.
Advocate for members and families to ensure access to appropriate services, programs, and community resources.
Facilitate resource utilization and service coordination across multiple care settings.
Provide field-based and telephonic case management services for SNP members.
Monitor healthcare services and member outcomes regardless of the site of care.
Track member progress and evaluate the effectiveness of interventions and care plans.
Identify changes in member conditions and coordinate timely interventions as needed.
Maintain accurate, thorough, and timely documentation in accordance with professional standards and organizational policies.
Ensure adherence to care management guidelines, regulatory requirements, and quality standards.
Support high-quality, cost-effective care guided by evidence-based clinical practice standards.
Promote quality outcomes through ongoing assessment, monitoring, and follow-up.