RN II Case Manager​/Pediatric Oncology

Overview

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. We strive to maintain an innovative and inclusive environment that allows employees to thrive.

Position: RN with care management responsibilities, including planning for the transition to the continuum of care. Provides mentorship and serves as a subject matter expert for projects and committees as needed.

• Assess patient’s clinical need against established guidelines to ensure the level of care and length of stay are medically appropriate for inpatient care.
• Evaluate the necessity, appropriateness, and efficiency of medical services and procedures.
• Coordinate and assist in the implementation of plans for members.
• Monitor and coordinate services outside the network or local area; negotiate fees as appropriate; coordinate with patients, families, physicians, hospitals, and other external customers regarding care from diagnosis to outcome.
• Coordinate the delivery of high-quality, cost-effective care supported by clinical practice guidelines addressing the continuum of care.
• Monitor patient care activities and outcomes for appropriateness and effectiveness.
• Advocate for members and families across sites to coordinate resource utilization and service evaluation.
• Encourage member participation and compliance in case/disease management programs.
• Document accurately according to standards of practice and current policies.
• Interact with multidisciplinary teams to ensure continuity and efficiency as the member is managed along the continuum of care.
• Understand fiscal accountability and its impact on resource utilization and self-care outcomes.
• Evaluate care through problem solving, variance analysis, and participation in quality improvement to improve outcomes.
• Serve as mentor/trainer to new RNs and other staff as needed.
• Act as subject matter expert for respective area on projects and may assume leadership activities in team lead absences.
• Represent clinical teams in committee meetings and present required reports.
• Serve as subject matter expert for user acceptance testing of the medical management system.

• Outreaches to members identified as needing Clinical Advocate services.
• Applies critical thinking and clinical expertise to maximize outcomes in a fast-paced environment.
• Builds trusting relationships with members and families using motivational interviewing.
• Becomes knowledgeable in ASO client employer-sponsored benefits to assist members with questions about medical benefits, claims, care coordination, and complex needs through clear explanations and education.
• Advocates for members throughout their healthcare journey by coordinating with members, family, physician, hospital, and other external customers regarding care from diagnosis to outcome.
• Focuses on a whole-person approach to reduce burden and improve well-being (physical, mental, emotional).
• Schedule:
  
  8- or 10-hour workdays, Monday through Friday, varying between 8:00 a.m. and 11:00 p.m.

• High School Diploma/GED required.
• Bachelor’s degree preferred or relevant experience in lieu of degree.
• Minimum of two (2) years of clinical experience.
• Minimum of two (2) years of health care payer experience.

Utilization inpatient case management details do not apply to the RN II role within HCS. RNs are required to work a specified number of weekends and holidays to meet regulatory and accrediting body standards; requirements may vary by department.

• Active unrestricted NJ RN license or active compact license required.
• Addendum: CCM certification preferred for Horizon Clinical Advocate roles.

• Proficient in Windows-based PC software (MS Office) and intranet/internet applications.
• Knowledge of hospital structures, payment systems, and case/care/disease management principles.
• Knowledge of utilization, case and/or disease management…