RN II - Primary Nurse Care

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

1d•$79,100 - $105,945

About The Position

This position performs registered nurse duties for the Primary Nurse population, using established guidelines to ensure an appropriate level of care, plan transitions across the continuum of care, and develop member-centered plans of care. Primary Nurses reach out to high-risk members and work to engage them in preventive care opportunities and screenings when possible. The role performs care management duties as assigned by management and serves as a mentor or trainer to new RNs and other staff as needed. Positions involving ASO accounts may require travel for on-site availability. The role assesses clinical needs and medical services, coordinates care across providers and settings, supports members and families, and monitors care activities and outcomes. It also documents care according to applicable standards and policies, contributes to quality improvement, and presents clinical cases during audits conducted by external review organizations. Travel may be required primarily within New Jersey, with occasional travel in the tri-state area. Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware. The listed salary range is $79,100–$105,945. Horizon describes its compensation and benefits package as including comprehensive health benefits, retirement plans, generous PTO, incentive plans, wellness programs, paid volunteer time off, and tuition reimbursement.

Requirements

High school diploma or GED required.
Bachelor's degree preferred, or relevant experience in lieu of a degree.
Minimum of two years of clinical experience required.
Minimum of three years of experience in the health care delivery system or industry required.
Active, unrestricted RN license required; New Jersey license and/or compact license required.
Valid driver's license and insurance required.
Proficiency with personal computers and supporting software in a Windows-based environment, including Microsoft Word, Excel, PowerPoint, and Outlook.
Working knowledge of case, care, and disease management principles.
Working knowledge of utilization, case, and/or disease management processes.
Working knowledge of utilization management principles.
Basic knowledge of health care contracts and benefit eligibility requirements.
Knowledge of hospital structures and payment systems.
Adaptability and flexibility, analytical ability, compassion, information and knowledge sharing, interpersonal and client relationship skills, sound decision-making, active listening, organization and priority-setting, problem-solving and critical thinking, teamwork, time management, and written and oral communication skills.
Must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Nice To Haves

Bachelor's degree.
Experience with both acute and chronic conditions.
Health care payer experience.
Knowledge of intranet and internet applications.
Understanding of fiscal accountability and its impact on resource utilization and self-care outcomes.
Bilingual proficiency.

Responsibilities

Assess members' clinical needs against established guidelines and standards to determine whether services are medically appropriate and aligned with benefit structures.
Facilitate responses to gaps in care and connect identified high-risk members with appropriate care settings for annual wellness visits, including collaboration with treating providers.
Evaluate the necessity, appropriateness, and efficiency of medical services and procedures for acute and chronic health care needs.
Develop, coordinate, and assist with implementing individualized member care plans, identifying barriers to self-management and optimal wellness.
Coordinate with members, families, physicians, hospitals, and other external customers regarding appropriate care from diagnosis through outcome.
Coordinate high-quality, cost-effective care using clinical practice guidelines across the continuum of care, including transitional care.
Monitor members' 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 in case and disease management programs.
Document accurately and comprehensively according to standards of practice and current organizational policies.
Communicate with multidisciplinary teams by telephone and/or in person to support continuity and efficiency across the continuum of care.
Evaluate care by problem-solving, analyzing variances, and participating in quality improvement efforts to enhance member outcomes.
Mentor and train new RNs and other staff as needed.
Present clinical cases during audits conducted by external review organizations.
Perform other duties as assigned by management.