Horizon Blue Cross Blue Shield of New Jersey
Location
Newark, New Jersey
Salary
$70,500 - $94,395 / YEAR
Perform clinical assessments for PCA and MDC services to ensure appropriate levels of care and medical necessity. Coordinate high-quality, cost-effective care by collaborating with patients, families, and multidisciplinary healthcare teams.
Requires an active unrestricted New Jersey RN license and a high school diploma, with a bachelor's degree and two years of clinical experience preferred. Must possess a valid NJ driver's license, insurance, and a vehicle for daily local travel.
This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized. What You'll Do Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure. Evaluates the necessity, appropriateness and efficiency of service provided. Develops, coordinates and assists in implementation of services to meet the needs of the members. 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. Refers members to MLTSS when appropriate. Educates members on the availability of SNP if appropriate. 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. 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. Completes other assigned functions as requested by management. Performs duties as assigned by management. What You Bring Education/Experience: High School Diploma/GED required. Bachelor's degree preferred or relevant experience in lieu of degree. A minimum of two (2) years clinical experience is preferred. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License Required.
RN 1.5 Completes NJ Choice Home Care Assessments for new referrals to MLTSS. Assists with MLTSS Case Management when necessary, to cover for FMLA or to maintain MLTSS Caseloads below contractual obligations. Provide support when needed to MLTSS Care Management Staff, including but not limited to Annual Assessment, 90 day and/or Post Hospital visits. Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
$70,500 - $94,395 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 Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. 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. About Us We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too. Our Mission We empower our members to achieve their best health. Our Vision We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.
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