RN II/ONCOLOGY CASE MANAGER (REMOTE)

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

1d•$79,100 - $105,945•Remote

About The Position

This position performs registered nurse duties using established guidelines to ensure members receive an appropriate level of care and to plan transitions across the continuum of care. The RN performs care-management duties as assigned, mentors and trains new RNs and other staff as needed, and serves as a subject matter expert for projects and committees. The role may also assume team-lead activities in a team lead’s absence and represent clinical teams at committee meetings, including presenting required reports and supporting user acceptance testing for the medical management system. The role assesses medical necessity and care appropriateness, coordinates services and care plans, monitors outcomes and resource use, and advocates for members and families throughout their healthcare journey. For Horizon Clinical Advocate roles, responsibilities also include outreach to identified members, building trusting relationships using motivational interviewing, explaining employer-sponsored benefits and related processes in plain language, and supporting members’ overall 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 roles require a specified number of weekends and holidays, which may vary according to departmental business needs. Horizon 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 RN 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, or disease management principles.
Working knowledge of utilization, case, and/or disease management operations and processes.
Knowledge of healthcare contracts and benefit eligibility requirements.
Knowledge of mentoring in utilization, case, or disease management operations.
For Utilization Management roles, willingness to work a specified number of weekends and holidays as required by regulatory and accrediting standards and department needs.
For Horizon Clinical Advocate roles, ability to be an empathetic critical thinker.
For Horizon Clinical Advocate roles, excellent communication and organizational skills and a high tolerance for ambiguity.
For Horizon Clinical Advocate roles, ability to understand and communicate member benefits, claims, and coordination using advocacy principles and effective utilization.
For Horizon Clinical Advocate roles, ability to work collaboratively and demonstrate teamwork, analytical and critical-thinking skills, and interpersonal skills.
For Horizon Clinical Advocate roles, exceptional multichannel communication and interpersonal skills, including the ability to explain complex concepts clearly and compassionately.
Skills and abilities include adaptability and flexibility, analytical ability, compassion, interpersonal and client relationship skills, information and knowledge sharing, judgment, listening, planning and priority setting, problem solving, teamwork, time management, and written and oral communication and organizational skills.
Must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

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

Responsibilities

Assess patients’ clinical needs against established guidelines and standards to determine the medical appropriateness of inpatient level of care and length of stay.
Evaluate the necessity, appropriateness, and efficiency of medical services and procedures.
Coordinate and assist in implementing plans for members.
Monitor and coordinate services provided outside the network or local area, and negotiate fees when appropriate.
Coordinate with patients, families, physicians, hospitals, and other external customers regarding appropriateness of 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 across sites of service and evaluate outcomes for appropriateness and effectiveness.
Advocate for members and families across care settings to coordinate resource utilization and evaluate services.
Encourage member participation and compliance with case- and disease-management programs.
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.
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 activities to enhance member outcomes.
Mentor and train new RNs and other staff as needed.
Serve as a subject matter expert for projects in the relevant area.
May assume leadership activities in the absence of a team lead.
Represent clinical teams at committee meetings and present required reports.
Serve as a subject matter expert for user acceptance testing of the medical management system.
For Horizon Clinical Advocate roles, contact members identified as needing Clinical Advocate services.
For Horizon Clinical Advocate roles, use clinical expertise and critical thinking while interacting with members and families in a fast-paced environment.
For Horizon Clinical Advocate roles, build trusting relationships using motivational interviewing techniques.
For Horizon Clinical Advocate roles, explain benefits and provide education and resources in plain language to help members with benefits, claims, care coordination, and complex needs.
For Horizon Clinical Advocate roles, advocate for members and coordinate with their families, physicians, hospitals, and other external customers throughout care.
For Horizon Clinical Advocate roles, support a whole-person approach addressing members’ physical, mental, and emotional well-being.