This field based position is accountable for the assessment and case management of Dual Special Needs members using established guidelines to ensure appropriate level of care as well as developing a member centric plan of care.Responsibilities:
Assesses patient's clinical needs 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 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.
.Documents accurately and comprehensively based on the standards of practice and current organization policies.
Provides field based and/or telephonic case management activities specific to the Dual Special Needs program.
The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.
Requires a High School diploma or GED. Bachelor's degree from an accredited college or university preferred.
Requires a minimum of three (3) years broad clinical experience.
Requires a minimum of three (3) years experience in home care, discharge planning, or case management. Preferably with the elderly frail population.
Requires a minimum of three (3) year experience in the health care delivery system/industry.
Requires strong knowledge of the standards of practice for case managers.
Requires strong knowledge of managed care principles and concepts including Health Plan Effectiveness Data and Information Sheet (HEDIS).
Required knowledge of medical terminology.
Prefers knowledge of managed care principles.
Prefer experience with elderly frail population
Skills and Abilities:
Requires strong organizational skills.
Requires strong oral and written communication skills.
Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)
Requires good problem solving and conflict resolution skills.
Requires good presentation skills.
Requires ability to work with limited daily supervision
This is a field based position, daily local travel is required.
Requires a car with valid New Jersey State License and Insurance
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.