RNI-DSNP-Passaic and Sussex NJ Counties at Horizon Blue Cross Blue Shield of New Jersey in Hopewell, New Jersey

Job Description:

Job Summary:

This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.

Responsibilities:

• Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.


• Evaluates the necessity, appropriateness and efficiency of service provided.


• Develops, coordinates and assists in implementation of services to meet the needs of the members.


• 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.


• Refers members to MLTSS when appropriate.


• Educates members on the availability of SNP if appropriate.


• 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.


• Performs duties as assigned by management.

Qualifications:

• Requires an associates or bachelors degree (or higher) in nursing and/OR accredited diploma nursing school.


• A minimum of two (2) years clinical experience is preferred

Additional licensing, certifications, registrations:

• Active Unrestricted NJ RN License Required.

Knowledge:

• 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

Skills and Abilities:

• 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)

Travel:

• This is a field based position, daily local travel is required.


• Requires a car with valid New Jersey State License and Insurance

Addendum:

• Completes NJ Choice Home Care Assessments for new referrals to MLTSS.


• Assists with MLTSS Case Management when necessary, to cover for FMLA or to maintain MLTSS Caseloads below contractual obligations.


• Provide support when needed to MLTSS Care Management Staff, including but not limited to Annual Assessment, 90 day and/or Post Hospital visits.

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.

Apply Now