[Hiring] RN II - Pediatrics @Horizon Blue Cross Blue Shield of New Jersey

Role Description

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.

What You'll Do

• Coordinates and assists in implementation of plan for members.
• 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.
• 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.
• 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.
• 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.
• Serves as mentor/trainer to new RN's and other staff as needed.
• Acts as subject matter expert for respective area for projects.
• May assume leadership type activities in team leads absence.
• Represent clinical teams within committee meetings.
• Present reports required at committee meetings.
• Subject matter expert for user acceptance testing for medical management system.
• Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment.
• Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques.
• Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional.

Qualifications

• 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 minimum of two (2) years’ experience with health care payer experience.
• Active Unrestricted NJ RN License or active Compact License Required.
• CCM certification preferred.

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

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Salary Range

$79,100 - $105,945