Job Description: • Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure. • Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider. • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs. • Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness. • Coordinates with members, 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 including transitional 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 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. • Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Requirements: • High School Diploma/GED required • Bachelor degree preferred or relevant experience in lieu of degree • Requires a minimum of two (2) years clinical experience • Requires a minimum of three (3) years' experience in the health care delivery system/industry • Active Unrestricted RN License Required; NJ License required and/or Compact License • Valid Driver's License and Insurance • Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook • Requires working knowledge of case/care/disease management principles • Requires working knowledge of operations of utilization, case and/or disease management processes • Requires working knowledge of principles of utilization management • Requires basic knowledge of health care contracts and benefit eligibility requirements • Requires knowledge of hospital structures and payment systems Benefits: • Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement
A healthcare organization affiliated with Horizon Blue Cross Blue Shield of New Jersey providing care management, utilization review, and member services.
