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. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.
What You'll Do
- Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.
- Evaluates the necessity, appropriateness and efficiency of service provided.
- Develops, coordinates and assists in implementation of services to meet the needs of the members.
- 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.
- Refers members to MLTSS when appropriate.
- Educates members on the availability of SNP if appropriate.
- 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.
- Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
- Completes NJ Choice Home Care Assessments for new referrals to MLTSS.
- Assists with MLTSS Case Management when necessary, to cover for FMLA or to maintain MLTSS Caseloads below contractual obligations.
- Provide support when needed to MLTSS Care Management Staff, including but not limited to Annual Assessment, 90 day and/or Post Hospital visits.
- Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
- Completes other assigned functions as requested by management.
- Performs duties as assigned by management.
What You Bring
Education/Experience
- High School Diploma/GED required.
- Bachelor degree preferred or relevant experience in lieu of degree.
- A minimum of two (2) years clinical experience is preferred.
Additional licensing, certifications, registrations
- Active Unrestricted NJ RN License Required.
Knowledge
- Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
- Working knowledge of case/care management principles.
- 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 and Abilities
- Analytical
- Compassionate
- Interpersonal & Client Relationship Building Skills
- Sound Decision Making
- Active Listening
- Organization/Planning/Priority Setting
- Problem Solving/Critical Thinking
- Team Player
- Time Management
- Written/Oral Communication Skills (Bi-lingual preferred)
Travel (If Applicable)
- This is a field based position, daily local travel is required.
- Requires a car with valid New Jersey State License and Insurance.
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!
Salary Range
$70,500 - $94,395
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. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Disclaimer
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.