RN II, -Pediatrics Case Manager-REMOTE

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.

About the Role
This position is responsible for performing RN duties for the Primary Nurse population using established guidelines to ensure appropriate level of care, as well as, planning for the transition to the continuum of care and developing a member centric plan of care. Primary Nurses will outreach to high risk members and will work to engage members in preventative care opportunities & screenings when possible. This position will perform duties and types of care management as assigned by management. Serves as a mentor/trainer to new RN's and other staff as needed. Positions involving ASO accounts may require some travel for on-site availability.
What You'll Do

• 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.
• Serves as mentor/trainer to new RN's and other staff as needed
• Presents clinical cases during audits conducted by external review organizations.

What You Bring

Education/Experience:

• Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
• Requires a minimum of two (2) years clinical experience. Experience with both acute and chronic conditions preferred.
• Requires a minimum of three (3) years' experience in the health care delivery system/industry.
• Experience with health care payer experience strongly preferred.

Additional licensing, certifications, registrations:

• Active Unrestricted RN License Required; NJ License Preferred
• Requires a valid Driver's License and Insurance.

Knowledge:

• 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. Prefers knowledge in the use of intranet and internet applications.
• 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.
• Prefers understanding of fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

Skills and Abilities:

• Bi-lingual proficiency preferred.
• Adaptability/Flexibility
• Analytical
• Compassion
• Information/Knowledge Sharing
• Interpersonal & Client Relationship
• Sound decisi