RN II – Primary Nurse Care, Case Management

NJM Insurance Group

Primary Nurse managing care for high risk members utilizing established guidelines to ensure appropriate level of care. Engaging members in preventative care opportunities while collaborating with multidisciplinary teams.

Posted 7/1/2026full-timeRemote • New Jersey • 🇺🇸 United StatesJuniorMid-Level💰 $79,100 - $105,945 per yearWebsite

About the role

Key responsibilities & impact

Assess 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
Facilitate response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider
Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs
Develop, coordinate and assist in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness
Coordinate with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
Coordinate 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
Monitor member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided
Encourage member participation and compliance in the case/disease management program efforts
Document accurately and comprehensively based on the standards of practice and current organization policies
Interact and communicate with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care
Evaluate care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
Serve as mentor/trainer to new RN's and other staff as needed
Present clinical cases during audits conducted by external review organizations
Perform other duties as assigned by management

Requirements

What you’ll need

High School Diploma/GED required
Bachelor degree preferred or relevant experience in lieu of degree
Minimum of two (2) years clinical experience
Experience with both acute and chronic conditions preferred
Minimum of three (3) years' experience in the health care delivery system/industry
Health care payer experience strongly preferred
Active Unrestricted RN License Required; NJ License required and/or Compact License
Requires a valid Driver's License and Insurance
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
Working knowledge of case/care/disease management principles
Working knowledge of operations of utilization, case and/or disease management processes
Requires working knowledge of principles of utilization management
Basic knowledge of health care contracts and benefit eligibility requirements
Knowledge of hospital structures and payment systems.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Clinical ExperienceUtilization ManagementDisease ManagementHealth Care Contracts KnowledgeMedical Service Evaluation

Soft Skills

CommunicationProblem SolvingMentoringAdvocacyCollaboration

Certifications

RN LicenseNJ LicenseCompact License