RN II - Case Management

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

6d•$79,100 - $105,945

About The Position

This position performs registered nurse duties using established guidelines to ensure the appropriate level of care and plan transitions to the continuum of care. The RN performs care management duties as assigned, mentors and trains new RNs and other staff, serves as a subject matter expert for projects and committees, and may assume team-lead activities when the team lead is absent. The role evaluates clinical needs, medical necessity, appropriateness, efficiency, and outcomes of care across care settings. It coordinates services and resources with members, families, physicians, hospitals, and other external customers, supporting high-quality, cost-effective care and member participation in case or disease management programs. Documentation must meet standards of practice and current organizational policies. For Horizon Clinical Advocate assignments, the RN contacts identified members, applies clinical expertise and critical thinking, builds trusting relationships using motivational interviewing techniques, explains benefits and provides education and resources, and advocates for members throughout their healthcare journey. The role takes a whole-person approach, addressing physical, mental, and emotional well-being while reducing unnecessary burdens on members. The schedule is an 8- or 10-hour workday, Monday through Friday, with work hours varying between 8 a.m. and 11 p.m. Utilization Management RNs are required to work a specified number of weekends and holidays; requirements may vary based on department business needs. Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED required.
At least two years of clinical experience required.
At least two years of healthcare payer experience required.
Active unrestricted New Jersey RN license or active Compact License required.
Proficiency with personal computers and supporting software in a Windows-based environment, including Microsoft Word, Excel, PowerPoint, and Outlook.
Knowledge of intranet and internet applications.
Knowledge of hospital structures and payment systems.
Working knowledge of case, care, and disease management principles and utilization, case, and/or disease management processes.
Knowledge of healthcare contracts and benefit eligibility requirements.
Knowledge of mentoring in utilization, case, and disease management operations.
For Clinical Advocate assignments, ability to be an empathetic critical thinker, communicate and organize effectively, and work with ambiguity.
For Clinical Advocate assignments, ability to understand and communicate member benefits, claims, and coordination while focusing on advocacy and effective utilization.
For Clinical Advocate assignments, ability to work collaboratively as a team player and demonstrate analytical, critical-thinking, and interpersonal skills.
For Clinical Advocate assignments, exceptional multichannel communication and interpersonal skills, including the ability to explain complex concepts clearly and compassionately.
Skills and abilities include adaptability and flexibility, analytical skills, compassion, interpersonal and client relationship skills, information and knowledge sharing, judgment, listening, planning and priority setting, problem solving, teamwork, time management, and written, oral, and organizational communication.
Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
Utilization Management RNs must work a specified number of weekends and holidays, with requirements varying by department business needs.

Nice To Haves

Bachelor’s degree preferred; relevant experience may be accepted in lieu of a degree.
Certified Case Manager (CCM) certification preferred for Horizon Clinical Advocate roles.
Active listening and motivational interviewing experience strongly preferred.

Responsibilities

Assess patients’ clinical needs against established guidelines or standards to determine whether the level of care and length of stay are medically appropriate for inpatient care.
Evaluate the necessity, appropriateness, and efficiency of medical services and procedures.
Coordinate and assist with implementation of plans for members.
Monitor and coordinate services delivered outside the network or local area, and negotiate fees when appropriate.
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 the plan’s clinical practice guidelines across the continuum of care.
Monitor medical care activities and outcomes across sites of service for appropriateness and effectiveness.
Advocate for members and families across care settings to coordinate resource utilization and evaluate services.
Encourage member participation and compliance in case and disease management programs.
Document accurately and comprehensively in accordance with professional practice standards and organizational policies.
Communicate with multidisciplinary teams by telephone and/or in person to promote continuity and efficiency throughout the continuum of care.
Apply fiscal accountability and consider its impact on resource utilization and self-care outcomes.
Evaluate care, solve problems, analyze variances, and participate in quality improvement efforts to enhance member outcomes.
Mentor and train new RNs and other staff as needed.
Serve as a subject matter expert for projects and the respective area; provide subject matter expertise for medical management system user acceptance testing.
May assume leadership activities in the team lead’s absence.
Represent clinical teams at committee meetings and present required reports.
For Clinical Advocate assignments, contact identified members and build trusting relationships with members and families using motivational interviewing techniques.
For Clinical Advocate assignments, explain benefits and provide education and resources in plain language, including support with medical benefits, claims, care coordination, and other complex needs.
For Clinical Advocate assignments, advocate for members throughout their healthcare journey and support their physical, mental, and emotional well-being.