DSNP Care Manager - Hudson & Passaic Counties

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.

About the role

This field-based position is accountable for the assessment and case management of Dual Special Needs members using established guidelines to ensure appropriate level of care as well as developing a member-centric plan of care.

Responsibilities

• Assesses patient's clinical needs 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 provided.
• 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 patient'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.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Provides field-based and/or telephonic case management activities specific to the Dual Special Needs program.

Requirements

• High School Diploma/GED required.
• Bachelor's degree preferred or relevant experience in lieu of degree.
• Minimum of three (3) years broad clinical experience.
• Minimum of three (3) years experience in home care, discharge planning, or case management, preferably with the elderly frail population.
• Minimum of three (3) years experience in the health care delivery system/industry.
• Active unrestricted NJ SW/RN/LPN License or CSW required.

Qualifications

• Strong knowledge of the standards of practice for case managers.
• Strong knowledge of managed care principles and concepts including Health Plan Effectiveness Data and Information Sheet (HEDIS).
• Knowledge of medical terminology.
• Experience with elderly frail population preferred.

Skills

• Strong organizational skills.
• Strong oral and written communication skills.
• Good PC skills and ability to utilize Microsoft Office applications (Excel, Access, Word, etc.).
• Good problem-solving and conflict resolution skills.
• Good presentation skills.
• Ability to work with limited daily supervision.

Travel

This is a field-based position; daily local travel is required. Requires a car with valid New Jersey State License and Insurance.

Pay

Salary Range: $63,000 - $84,420. 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.

Benefits

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

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.