What You'll Do Responsibilities:

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. Performs other duties as assigned by management.

Disclaimer:

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.

What You Bring Education/Experience:

High School Diploma/GED required. Bachelor degree preferred or relevant experience in lieu of degree. 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 required and/or Compact License. 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 decision making. Active listening. Organization Planning/Priority Setting. Problem Solving/Critical Thinking. Team Player. Time Management. Written/Oral Communications.

Travel:

Travel primarily within State of NJ may be required. Occasional travel in the tri-state area may also be required. 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!

Salary Range:

$79,100 - $105,945 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. 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