Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

Responsibilities:
Performs the following job responsibilities under the direction/supervision of an RN:

• 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 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 on site 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.
• Performs special projects as assigned by management.

Education/Experience:

• Prefers an Associates degree from an accredited college or university in health care management or related field.
• Requires a minimum of one-year clinical experience in an acute care facility.
• Requires a minimum of one-year experience in the health care delivery system/industry.
• Prefers quality initiative experience.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ LPN License Required

Knowledge:

• Required knowledge of medical terminology.
• Prefers knowledge of managed care principles.

Skills and Abilities:

• Requires excellent oral and written communication skills.
• Requires excellent organizational skills.
• Requires the ability to use sound judgment and resolve problems with moderate guidance from lead staff and/or supervisor.
• Requires strong analytical skills and the ability to use sound judgment and resolve problems with minimal guidance or supervisor.
• Requires strong interpersonal skills.
• Requires the skill to communicate effectively to all levels of employees.
• Require the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.
• Requires good PC skills and the ability to manage applicable software.

This 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.

Salary Range:

This 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:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon 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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.