Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
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.
Responsibilities:
- Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members' needs.
- Evaluates the necessity, appropriateness and efficiency of services provide.
- Develops, coordinates and assists in implementation of members- individualized plan of care.
- 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 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 provide.
- Encourages member participation and compliance in the program.
- 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.
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.
Education/Experience:
- High School Diploma/GED required.
- Bachelor 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.
Knowledge:
- Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
- Working knowledge of case/care management principles.
- Working knowledge of principles of utilization management.
- Prefers basic knowledge of health care contracts and benefit eligibility requirements.
- Prefers knowledge of hospital structures and payment systems.
Skills and Abilities:
- Analytical
- Compassionate
- Interpersonal & Client Relationship Building Skills
- Sound Decision Making
- Active Listening
- Organization/Planning/Priority Setting
- Problem Solving/Critical Thinking
- Team Player
- Time Management
- Written/Oral Communication Skills (Bi-lingual preferred)
Travel :
- This is a field based position, daily local travel is required.
Addendum:
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.