RN II- CASE MGR.TRANSPLANT(REMOTE) HCC

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

3d•$79,100 - $105,945•Remote

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. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed. The Transplant Case Manager acts as an individual’s primary advocate and care coordinator throughout the entire transplant journey, from initial evaluation and education to post-transplant recovery and long-term care. The Transplant Case Manager navigates complex medical, social, and financial barriers by coordinating with multiple providers and agencies, ensuring appropriate care access, and providing crucial support to individuals and their families during a challenging and emotional process.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Requires a minimum of two (2) years clinical experience.
Requires minimum of two (2) years’ experience with health care payer experience.
Active Unrestricted NJ RN License or active Compact License Required.
CCM certification preferred.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook).
Should be knowledgeable in the use of intranet and internet applications.
Requires knowledge of hospital structures and payment systems.
Requires working knowledge of case/care/disease management principles.
Requires working knowledge of operations of utilization, case and/or disease management processes.
Requires knowledge of health care contracts and benefit eligibility requirements.
Requires mentoring knowledge on the operations of utilization/case/disease management.
Requires ability to be an empathetic critical thinker.
Requires excellent communication and organizational skills and a high tolerance for ambiguity.
Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization.
Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills.
Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion.

Nice To Haves

Experience in active listening and motivational interviewing strongly preferred.

Responsibilities

Managing inbound clinical calls and maintaining a direct case management caseload.
Performing telephonic clinical triage, risk assessment, care coordination, member education, and referral management.
Conducting proactive outbound outreach to members, caregivers, providers, and community resources to support engagement, address barriers to care, facilitate transitions of care, and improve health outcomes through comprehensive case management services.
Assessing 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.
Evaluating the necessity, appropriateness and efficiency of medical services and procedures provided.
Coordinating and assisting in implementation of plan for members.
Monitoring and coordinating services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate.
Coordinating with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
Coordinating the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
Monitoring patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
Advocating for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
Encouraging member participation and compliance in the case/disease management program efforts.
Documenting accurately and comprehensively based on the standards of practice and current organization policies.
Interacting and communicating with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
Understanding fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
Evaluating care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Serving as mentor/trainer to new RN's and other staff as needed.
Acting as subject matter expert for respective area for projects.
Assuming leadership type activities in team leads absence.
Representing clinical teams within committee meetings.
Presenting reports required at committee meetings.
Serving as subject matter expert for user acceptance testing for medical management system.
Outreaching to members identified by Horizon as needing Clinical Advocate services.
Applying critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment.
Building trusting relationships with members and their families utilizing Motivational Interviewing techniques.
Becoming knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.
Advocating for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
Focusing on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional.