Southern Atlantic Counties)

Horizon Healthcare Services•Hopewell, NJ

25d•Onsite

About The Position

This field-based position performs assessments for PCA and MDC services using established guidelines and assessments to ensure the appropriate level of care and services are authorized. The role assesses clinical needs, evaluates the necessity and effectiveness of care, and develops and coordinates services to meet member needs across the continuum of care. It also supports MLTSS care management and completes NJ Choice Home Care Assessments for new MLTSS referrals. Daily local travel is required.

Requirements

High school diploma or GED required.
Active, unrestricted New Jersey RN license required.
Proficiency with personal computers and supporting software in a Windows-based environment, including Microsoft Word, Excel, and PowerPoint, and Lotus Notes.
Working knowledge of case/care management principles.
Working knowledge of utilization management principles.
Daily local travel is required; must have a car, a valid New Jersey driver’s license, and insurance.

Nice To Haves

Bachelor’s degree preferred, or relevant experience in lieu of a degree.
At least two years of clinical experience preferred.
Knowledge of intranet and internet applications.
Basic knowledge of health care contracts and benefit eligibility requirements.
Knowledge of hospital structures and payment systems.
Bilingual communication skills preferred.

Responsibilities

Assess patients’ clinical needs against established guidelines and standards to ensure services are medically appropriate and aligned with member benefits.
Evaluate the necessity, appropriateness, and efficiency of services provided.
Develop, coordinate, and assist in implementing services that meet members’ needs.
Coordinate with patients, families, physicians, hospitals, and other external customers regarding appropriate care from diagnosis through outcome.
Coordinate high-quality, cost-effective care supported by clinical practice guidelines across the continuum of care.
Monitor medical care activities and outcomes across service settings for appropriateness and effectiveness.
Advocate for members and families across service sites to coordinate resource utilization and evaluate services.
Refer members to MLTSS when appropriate and educate members about SNP availability when appropriate.
Document accurately and comprehensively in accordance with practice standards and organizational policies.
Communicate with multidisciplinary teams by telephone and/or in person to support continuity and efficiency of care.
Consider fiscal accountability and resource utilization in working toward self-care outcomes.
Complete NJ Choice Home Care Assessments for new MLTSS referrals.
Assist with MLTSS Case Management as needed, including FMLA coverage and maintaining caseloads within contractual obligations.
Support MLTSS Care Management staff as needed, including annual assessments and 90-day and/or post-hospital visits.
Evaluate care, solve problems, analyze variances, and participate in the quality improvement program to enhance member outcomes.
Complete other functions and duties assigned by management.