RN II, Primary Nurse Care – Case Manager
NJM Insurance Group
full-time
Posted on:
Location Type: Remote
Location: New Jersey • United States
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Salary
💰 $79,100 - $105,945 per year
About the role
- 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.
Requirements
- High School Diploma/GED required
- Bachelor degree preferred or relevant experience in lieu of degree
- Requires a minimum of two (2) years clinical experience
- Requires a minimum of three (3) years' experience in the health care delivery system/industry
- Active Unrestricted RN License Required; NJ License required and/or Compact License
- Requires a valid Driver's License and Insurance
- Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook.
- 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
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical assessmentcare coordinationindividualized care plan developmentquality improvementutilization managementcase managementdisease managementmedical documentationproblem solvinghealth care delivery system knowledge
Soft Skills
advocacycommunicationcollaborationmentoringanalytical skillsinterpersonal skillsorganizational skillsteamworkefficiencymember engagement
Certifications
Active Unrestricted RN LicenseNJ LicenseCompact License