RN II/Care Manager-ONCOLOGY (REMOTE)

About the role

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.

Responsibilities

• Affirms patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• Collaborates and assists in implementing the plan for members.
• Maintains coordination and negotiation of fees for services rendered outside the network.
• Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiates fees for such services as appropriate.
• 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.
• Communicates and interacts 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.
• Serves as mentor/trainer to new RN's and other staff as needed.
• Acts as subject matter expert for respective area for projects.
• May assume leadership type activities in team lead absence.
• Represents clinical teams within committee meetings.
• Presents reports required at committee meetings.
• Acts as subject matter expert for user acceptance testing for medical management system.

Addendum For Horizon Clinical Advocate Roles

• Outreaches to members identified by Horizon as needing Clinical Advocate services.
• Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment.
• Becomes knowledgeable in ASO client employer-sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.
• Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Focuses on whole person approach, by eliminating "homework" or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional.

Schedule

• 8- or 10-hour workday Monday through Friday varying between 8am and 11pm.

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 minimum of two (2) years’ experience with health care payer experience.
• Utilization Management Only(Utilization Inpatient Case Management does NOT apply to RN II role within HCS): RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards.

Additional Licensing, Certifications, Registrations

• Active Unrestricted NJ RN License or active Compact License Required.

Addendum For Horizon Clinical Advocate Roles

• Certification in Care Management (CCM) preferred.

Knowledge

• Proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook).
• Knowledgeable in the use of intranet and internet applications.
• Working knowledge of hospital structures and payment systems.
• Working knowledge of case/care/disease management principles.
• Working knowledge of operations of utilization, case and/or disease management processes.
• Knowledge of health care contracts and benefit eligibility requirements.
• Mentoring knowledge on the operations of utilization/case/disease management.

Skills And Abilities

• Adaptability/Flexibility
• Analytical
• Compassion
• Interpersonal & Client Relationship Skills
• Information/Knowledge Sharing
• Judgment
• Listening
• Planning/Priority Setting
• Problem Solving
• Team Player
• Time Management
• Written/Oral Communication & Organizational Skills

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission-driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!

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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.