RN II - Pediatrics

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

2d•$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 across the continuum of care. The RN performs assigned care-management duties, serves as a mentor and trainer to new RNs and other staff, and acts as a subject matter expert for projects, committees, and user acceptance testing for the medical management system. The RN coordinates member care and services across providers and settings, monitors care and outcomes for appropriateness and effectiveness, supports resource utilization, and advocates for members and their families throughout the healthcare journey. The role applies clinical practice guidelines, case and disease management principles, critical thinking, and Motivational Interviewing to promote high-quality, cost-effective, whole-person care and positive outcomes. It also includes committee participation and reporting, quality improvement activities, and possible leadership duties in the absence of a team lead.

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 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, and disease management principles.
Working knowledge of utilization, case, and/or disease management operations and processes.
Knowledge of healthcare contracts and benefit eligibility requirements.
Mentoring knowledge related to utilization, case, and disease management operations.
Skills and abilities in adaptability and flexibility, analysis, compassion, interpersonal and client relationships, information and knowledge sharing, judgment, listening, planning and prioritization, problem solving, teamwork, time management, written and oral communication, and organization.

Nice To Haves

Bachelor’s degree, or relevant experience in lieu of a degree.
CCM certification is preferred for Horizon Clinical Advocate roles.

Responsibilities

Coordinate and assist in implementing plans for members.
Monitor and coordinate services rendered 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 members’ medical care activities across service settings and evaluate outcomes for appropriateness and effectiveness.
Advocate for members and families across care settings to coordinate resource use and evaluate services.
Encourage member participation and compliance in case and disease management programs.
Document accurately and comprehensively in accordance with practice standards and organizational policies.
Communicate with multidisciplinary teams by phone and/or in person to support continuity and efficiency of care.
Apply fiscal accountability and consider its effect 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 in the respective area and for user acceptance testing of the medical management system.
Assume leadership-type activities in the team lead’s absence.
Represent clinical teams at committee meetings and present required reports.
Apply critical thinking and clinical expertise in a fast-paced environment to maximize outcomes while interacting with members and families.
Build trusting relationships with members and families using Motivational Interviewing techniques.
Advocate consistently for members throughout their healthcare journey.
Use a whole-person approach to support members’ physical, mental, and emotional well-being while reducing unnecessary burdens.