Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or DelawarennJob Summary:nnThis 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. Responsibilities:nnAssesses 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.nnEvaluates the necessity, appropriateness and efficiency of medical services and procedures provided.nnCoordinates and assists in implementation of plan for members.nnMonitors 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.nnCoordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.nnMonitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.nnAdvocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.nnEncourages member participation and compliance in the case/disease management program efforts.nnDocuments accurately and comprehensively based on the standards of practice and current organization policies.nnInteracts 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.nnUnderstands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.nnEvaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.nnServes as mentor/trainer to new RN's and other staff as needed.nnActs as subject matter expert for respective area for projects.nnMay assume leadership type activities in team leads absence.nnRepresent clinical teams within committee meetingsnnPresent reports required at committee meetings.nnSubject matter expert for user acceptance testing for medical management system.nnDisclaimer:nThis job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.nnEducation/Experience:nnHigh School Diploma/GED required.nnBachelor's degree preferred or relevant experience in lieu of degree.nnRequires a minimum of two (2) years clinical experience.nnRequires minimum of two (2) years' experience with health care payer experience.nnStrongly prefer Case Management experience.nnAdditional licensing, certifications, registrations:nnActive Unrestricted NJ RN License or active Compact License Required.nnKnowledge:nnMust 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.nnRequires knowledge of hospital structures and payment systems.nnRequires working knowledge of case/care/disease management principles.nnRequires working knowledge of operations of utilization, case and/or disease management processes.nnRequires knowledge of health care contracts and benefit eligibility requirements.nnRequires mentoring knowledge on the operations of utilization/case/disease management.nnSkills and Abilities:nnAdaptability/FlexibilitynnAnalyticalnnCompassionnnInterpersonal & Client Relationship SkillsnnInformation/Knowledge SharingnnJudgmentnnListeningnnPlanning/Priority SettingnnProblem SolvingnnTeam PlayernnTime ManagementnnWritten/Oral Communication & Organizational SkillsnnSalary Range:nn$76,800 - $102,795nnThis compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:nnComprehensive health benefits (Medical/Dental/Vision)nnRetirement PlansnnGenerous PTOnnIncentive PlansnnWellness ProgramsnnPaid Volunteer Time OffnnTuition ReimbursementnnHorizon will consider reasonable accommodation requests as part of the recruiting and hiring process.nnHorizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.