RN Case Manager/Transition of Care (Field Based)-Ocean/Monmouth Counties

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

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.

*Employee will spend M-F (8a-5p) in Ocean & Monmouth hospitals supporting Braven member's transition of care into Horizon Case Managment.

Responsibilities:

• Assesses 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.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Coordinates and assists in implementation of plan for members.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
• Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Encourages member participation and compliance in the case/disease management program efforts.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
• Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Completes other assigned functions as requested by management.
   

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree
• Requires a minimum of two (2) years clinical experience.
• Active Unrestricted NJ RN License or active Compact License Required.

Utilization Management Only

RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.

Knowledge:

• Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook)  prefers knowledge in the use of intranet and internet applications.
• Prefers working knowledge of case/care management principles.
• Prefers working knowledge of principles of utilization management.
• Prefers basic knowledge of health care contracts and benefit eligibility requirements.
• Prefers knowledge of hospital structures and payment systems.

Skills and Abilities:

• Analytical
• Compassion
• Interpersonal & Client Relationship Skills
• Judgment
• Listening
• Planning/Priority Setting
• Problem Solving
• Team Player
• Time Management
• Written/Oral Communication & Organizational Skills
   

Horizon