Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Job Summary: 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. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed. 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. 2. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. 3. Coordinates and assists in implementation of plan for members. 4. 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. 5. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. 6. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. 7. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. 8. Encourages member participation and compliance in the case/disease management program efforts. 9. Documents accurately and comprehensively based on the standards of practice and current organization policies. 10. 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. 11. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. 12. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. 13. Serves as mentor/trainer to new RN's and other staff as needed. 14. Acts as subject matter expert for respective area for projects. 15. May assume leadership type activities in team leads absence. 16. Represent clinical teams within committee meetings 17. Present reports required at committee meetings. 18. Subject matter expert for user acceptance testing for medical management system. Addendum for HCS: This Job Profile is used by Horizon Casualty Services for their RN II role. Responsibilities listed below DO NOT apply to HCS: 4. 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. 6. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. 8. Encourages member participation and compliance in the case/disease management program efforts. 16. Represent clinical teams within committee meetings 17. Present reports required at committee meetings. 18. Subject matter expert for user acceptance testing for medical management system. Core Individual Contributor Competencies Personal and professional attributes that are critical to successful performance for Individual Contributors: Customer Focus Accountable Learn Communicate Education/Experience 1. Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. 2. Requires a minimum of two (2) years clinical experience. 3. Requires minimum of two (2) years’ experience with health care payer experience. Utilization Inpatient Case Management 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 (Utilization Inpatient Case Management does NOT apply to RN II role within HCS) Additional licensing, certifications, registrations 1. Active Unrestricted NJ RN License Required Knowledge - Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications. - Requires knowledge of hospital structures and payment systems. - Requires working knowledge of case/care/disease management principles. - Requires working knowledge of operations of utilization, case and/or disease management processes. - Requires knowledge of health care contracts and benefit eligibility requirements. - Requires mentoring knowledge on the operations of utilization/case/disease management. - Skills and Abilities - Adaptability/Flexibility - Analytical - Compassion - Interpersonal & Client Relationship Skills - Information/Knowledge Sharing - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational Skills Travel (If Applicable) 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. 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. Salary Range: $76,800 - $102,795 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes: Comprehensive health benefits (Medical/Dental/Vision) Retirement Plans Generous PTO Incentive Plans Wellness Programs Paid Volunteer Time Off Tuition Reimbursement 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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. About Us We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too. Our Mission We empower our members to achieve their best health. Our Vision We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.