DSNP (Field Based - Hudson County)

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

22h•$70,500 - $94,395•Onsite

About The Position

This field-based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessment tools to ensure that appropriate levels of care and services are authorized. The role evaluates clinical needs and healthcare services, supports service authorization, monitors utilization and member outcomes, and helps coordinate individualized care across the continuum. It also advocates for members and families, collaborates with providers and multidisciplinary teams, maintains accurate documentation, and contributes to quality improvement and care management initiatives. Travel throughout the assigned service area is required 100% of the time to conduct member assessments and support care coordination activities.

Requirements

High school diploma or GED required.
Minimum of two years of clinical nursing experience.
Minimum of two years of healthcare payer experience.
Active, unrestricted New Jersey Registered Nurse (RN) license or Compact RN license required.
Knowledge of case management, care management, and disease management principles.
Working knowledge of utilization management processes and practices.
Knowledge of healthcare contracts and benefit eligibility requirements.
Knowledge of hospital operations and healthcare reimbursement systems.
Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
Familiarity with intranet and internet-based applications.
Strong assessment, documentation, and care coordination skills.
Ability to travel 100% of the time throughout the assigned service area.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

Bachelor's degree, or an equivalent combination of education and relevant experience.
Experience working with PCA, MDC, SNP, Medicaid, Medicare, or managed care populations.
Experience conducting field-based assessments.
Experience supporting complex care coordination and community-based services.
Understanding of member advocacy principles and whole-person care approaches.
Knowledge of healthcare benefits, claims, and care coordination services.
Experience with motivational interviewing techniques.
Understanding of healthcare resource utilization and quality improvement practices.
Certified Case Manager (CCM) certification preferred for Clinical Advocate-related assignments.

Responsibilities

Conduct comprehensive member assessments using established guidelines and tools to determine appropriate levels of care and service needs.
Evaluate the necessity, appropriateness, and effectiveness of healthcare services and procedures.
Assess clinical needs and support service authorization based on established standards and program requirements.
Monitor healthcare utilization and member outcomes to ensure services remain appropriate and effective.
Coordinate and assist with implementation of individualized care plans.
Facilitate high-quality, cost-effective care across the continuum of care.
Coordinate services among providers, healthcare facilities, family members, and community resources.
Monitor and coordinate services delivered outside the local area or network when appropriate.
Support transitions between healthcare settings and levels of care.
Advocate for members and families to ensure access to appropriate healthcare services and resources.
Encourage member participation and compliance with care management and disease management programs.
Help members navigate healthcare services and address barriers to care.
Promote positive health outcomes through education, support, and ongoing engagement.
Partner with physicians, hospitals, caregivers, and multidisciplinary teams to support coordinated care delivery.
Build relationships with internal and external stakeholders and communicate to support continuity, quality, and efficiency of care.
Participate in discussions and initiatives that improve coordination among care teams.
Maintain accurate, timely, and comprehensive documentation in accordance with professional standards and organizational requirements.
Analyze care variances and identify opportunities to improve member outcomes.
Participate in quality improvement initiatives and operational enhancement efforts.
Apply sound clinical judgment and responsible resource utilization in decision-making.
Serve as a resource for peers and contribute to knowledge-sharing activities.
Participate in projects, committee work, and process improvement initiatives as needed.
Support operational and system-related activities that improve care management processes.
Travel throughout the assigned service area to conduct member assessments and support care coordination activities.