RN I

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. About the Role 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. What You'll Do Assess patient’s clinical need against established guidelines and/or standards to ensure the level of care and length of stay are medically appropriate for inpatient stay. Evaluate the necessity, appropriateness, and efficiency of medical services and procedures provided. Coordinate and assist in implementation of plans for members. Monitor and coordinate services rendered outside of the network and outside the local area, negotiating fees as appropriate. Coordinate with patient, family, physician, hospital, and other external customers regarding appropriateness of care from diagnosis to outcome. Coordinate delivery of high‑quality, cost‑effective care supported by clinical practice guidelines established by the plan for the entire continuum of care. Monitor patient medical care activities, regardless of site of service, and outcomes for appropriateness and effectiveness. Advocate for the member/family among various sites to coordinate resource utilization and evaluate services provided. Encourage member participation and compliance in case/disease management program efforts. Document accurately and comprehensively based on standards of practice and current organization policies. Interact and communicate with multidisciplinary teams, either telephonically and/or in person, striving for continuity and efficiency as the member is managed along the continuum of care. Understand fiscal accountability and its impact on utilization of resources, progressing to self‑care outcomes. Evaluate care by problem solving, analyzing variances, and participating in the quality improvement program to enhance member outcomes. Complete other assigned functions as requested by management. Qualifications Associate’s or bachelor’s degree (or higher) in nursing and/or a health‑related field, or accredited diploma nursing school. Minimum of two (2) years of clinical experience. Active unrestricted New Jersey Registered Nurse License. Proficiency in the use of personal computers and supporting software in a Windows‑based environment, including MS Office (Word, Excel, PowerPoint) and Lotus Notes. Working knowledge of intranet and internet applications. Working knowledge of case/care management principles. Working knowledge of utilization management principles. Basic knowledge of health care contracts and benefit eligibility requirements. Knowledge of hospital structures and payment systems. Skills and abilities: analytical, compassion, interpersonal & client relationship, judgment, listening, planning/priority setting, problem solving, team player, time management, writing/abiding, and organizational skills. Compensation and Benefits Salary Range: $70,500 - $94,395. This compensation range is specific to the job level and reflects education, experience, licensure, certifications, geographic location, and internal equity. Benefits include comprehensive health benefits (medical, dental, vision), retirement plans, generous PTO, incentive plans, wellness programs, paid volunteer time off, and tuition reimbursement. Equal Opportunity Horizon BCBSNJ 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. #J-18808-Ljbffr 100 Horizon Healthcare Services, Inc