RN II, Field - Somerset County
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 field based position is responsible for performing assessments of members using established guidelines to ensure appropriate level of care and develop a member centric plan of care.Responsibilities
- Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members' needs.
- Evaluates the necessity, appropriateness and efficiency of services provided.
- Develops, coordinates and assists in implementation of members- individualized plan of care.
- 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 member'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 program.
- 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.
- 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 Required
- Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel,PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
- Working knowledge of case/care management principles.
- 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
- Analytical
- Compassionate
- Interpersonal & Client Relationship Building Skills
- Sound Decision Making
- Active Listening
- Organization/Planning/Priority Setting
- Problem Solving/Critical Thinking
- Team Player
- Time Management
- Written/Oral Communication Skills (Bi-lingual preferred)
- This is a field based position, daily local travel is required.
- Requires a car with valid New Jersey State License and Insurance
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement