RN II - Case Management

Horizon Healthcare Services•Hopewell, NJ

About The Position

This position performs registered nurse duties using established guidelines to ensure an appropriate level of care and plan transitions across the continuum of care. The RN performs care management duties assigned by management, mentors and trains new RNs and other staff as needed, serves as a subject matter expert for projects and committees, and may take on team-lead activities in a team lead’s absence. The RN assesses clinical needs against established guidelines and standards, evaluates the medical necessity and appropriateness of services, coordinates member care, and monitors care and outcomes across settings. The role collaborates with members, families, physicians, hospitals, multidisciplinary teams, and other external partners to support continuity, effective resource use, and high-quality, cost-effective care. It also includes accurate documentation, participation in quality improvement, committee reporting, and user acceptance testing for the medical management system. For Horizon Clinical Advocate duties, the RN contacts members identified as needing support, builds trusting relationships using Motivational Interviewing techniques, explains benefits and provides education and resources, and advocates for members throughout their healthcare journey. The role uses a whole-person approach addressing physical, mental, and emotional well-being. The schedule is an 8- or 10-hour workday, Monday through Friday, with hours varying between 8 a.m. and 11 p.m. Utilization Management RNs must work a specified number of weekends and holidays; requirements may vary by department business needs. Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED required.
Minimum of two years of clinical experience.
Minimum of two years of health care payer experience.
Active unrestricted New Jersey RN license or active Compact License required.
Proficiency with personal computers and Windows-based software, 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, or disease management principles and utilization, case, and/or disease management operations.
Knowledge of health care contracts and benefit eligibility requirements.
Mentoring knowledge of utilization, case, and/or disease management operations.
Ability to work collaboratively as a team player, with analytical, critical-thinking, and interpersonal skills.
Strong communication and organizational skills, including the ability to explain complex concepts clearly and compassionately.
For Clinical Advocate duties, ability to think empathetically and tolerate ambiguity; ability to understand and communicate member benefits, claims, and coordination needs while applying advocacy principles and effective utilization.
For Utilization Management RNs, willingness to work a specified number of weekends and holidays, as required by regulatory and accrediting body standards and department business needs.

Nice To Haves

Bachelor’s degree, or relevant experience in lieu of a degree.
CCM certification for Horizon Clinical Advocate roles.
Experience in active listening and Motivational Interviewing.

Responsibilities

Assess patients’ clinical needs against established guidelines and standards to determine the appropriateness of inpatient level of care and length of stay.
Evaluate the necessity, appropriateness, and efficiency of medical services and procedures.
Coordinate and assist with implementation of care plans for members.
Monitor and coordinate services delivered outside the network or local area, and negotiate fees when appropriate.
Coordinate with members, families, physicians, hospitals, and other external customers regarding appropriate care from diagnosis through outcome.
Coordinate high-quality, cost-effective care across the continuum using clinical practice guidelines.
Monitor medical care activities across sites of service and assess their appropriateness and effectiveness.
Advocate for members and families across care settings, coordinating resource utilization and evaluating services.
Encourage member participation and compliance with case and disease management efforts.
Document accurately and comprehensively according to practice standards and organization policies.
Communicate with multidisciplinary teams by telephone and/or in person to support continuity and efficiency of care.
Apply fiscal accountability and consider the impact of resource utilization on care and self-care outcomes.
Evaluate care, solve problems, analyze variances, and participate in quality improvement activities 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; participate in committees and present required reports.
May assume leadership activities in the absence of a team lead.
Serve as a subject matter expert for user acceptance testing of the medical management system.
For Clinical Advocate duties, contact members identified as needing services and use clinical expertise and critical thinking to maximize outcomes.
Build trusting relationships with members and families using Motivational Interviewing techniques.
Explain benefits and provide education and resources in plain language, including assistance with medical benefits, claims, care coordination, and complex needs.
Use a whole-person approach to support members’ physical, mental, and emotional well-being.