RN I - Utilization Review

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

19h

About The Position

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.

Requirements

High School Diploma/GED required
Requires a minimum of two (2) years clinical experience.
Active Unrestricted NJ RN License or active Compact License Required.
Utilization Management Only RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.

Nice To Haves

Bachelor degree preferred or relevant experience in lieu of degree
Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook) prefers knowledge in the use of intranet and internet applications.
Prefers working knowledge of case/care management principles.
Prefers working knowledge of principles of utilization management.
Prefers basic knowledge of health care contracts and benefit eligibility requirements.
Prefers knowledge of hospital structures and payment systems.

Responsibilities

Assesses 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, 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.