RN II

Job Summary

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

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.

• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.

• 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 negotiates 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.

• Outreaches to members identified by Horizon as needing Clinical Advocate services.

• 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.

• Becomes knowledgeable in ASO client employer-sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.

• 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…