Complex Case Manager, RN – Maternity/NICU
Highmark Health
RN Case Manager
NJM Insurance Group
full-time
Posted on:
Location Type: Remote
Location: Remote • Connecticut, New Jersey, New York, Pennsylvania • 🇺🇸 United States
Visit company websiteSalary
💰 $69,500 - $93,030 per year
Job Level
JuniorMid-Level
About the role
- Assesses patient's clinical need against established guidelines and/or standards to ensure appropriate level of care and length of stay
- Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided
- Coordinates and assists in implementation of plan for members
- Monitors and coordinates services rendered outside of the network and negotiates fees as appropriate
- Coordinates with patient, family, physician, hospital and other external customers regarding appropriateness of care from diagnosis to outcome
- Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines addressing the continuum of care
- Monitors patient's medical care activities and outcomes for appropriateness and effectiveness
- Advocates for the member/family to coordinate resource utilization and evaluate services provided
- Encourages member participation and compliance in case/disease management efforts
- Documents accurately and comprehensively based on standards of practice and organization policies
- Interacts and communicates with multidisciplinary teams telephonically and/or in person to ensure continuity and efficiency
- Understands fiscal accountability and its impact on resource utilization and self-care outcomes
- Evaluates care by problem solving, analyzing variances and participating in quality improvement programs
- Completes other assigned functions as requested by management
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
- Active Unrestricted NJ RN License or active Compact License Required
- Utilization Management Only RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards
- Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
- Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook)
- Prefers knowledge in the use of intranet and internet applications
- Prefers working knowledge of case/care management principles
- Prefers 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: Analytical; Compassion; Interpersonal & Client Relationship Skills; Judgment; Listening; Planning/Priority Setting; Problem Solving; Team Player; Time Management; Written/Oral Communication & Organizational Skills
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
- Comprehensive compensation and benefits package
ATS Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical assessmentutilization managementcase managementquality improvementresource utilizationmedical services evaluationcare coordinationfiscal accountabilitydocumentation standardshealth care contracts
Soft skills
analytical skillscompassioninterpersonal skillsjudgmentlistening skillsplanningproblem solvingteam playertime managementwritten communication
Certifications
NJ RN LicenseCompact License
