RN II, Commercial Risk Adjustment

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Execute care management responsibilities aimed at high-risk members within commercially risk-adjusted populations.

• Conduct annual assessments of high-risk members' health status and engage them in preventive care opportunities and screenings.

• Assist high-risk members in navigating to suitable care settings and annual wellness visits.

• Coordinate transitions from RAM RN to care management RN.

• Promote member involvement and adherence in case/disease management programs.

• Collaborate with RAM Business Analysts and Manager to connect with at-risk members.

• Implement clinical engagement strategies utilizing RAM insights, member outreach calls, and retail pharmacy information.

• Create ad-hoc clinical outreach strategies and analyze RAM analytical reports.

• Develop and enhance member outreach initiatives, which may include physician or pharmacy visits.

• Evaluate clinical needs against established guidelines and create, coordinate, and assist with personalized care plans.

• Assess the necessity, appropriateness, and efficiency of medical services.

• Work with members, families, physicians, hospitals, and external customers throughout the continuum of care.

• Monitor medical care activities and their outcomes for appropriateness and effectiveness.

• Advocate for members and families across various care sites.

• Ensure accurate and comprehensive documentation in line with standards and policies.

• Evaluate care, analyze variances, and engage in quality improvement initiatives.

• Mentor and train new RNs and other team members as necessary.

• Carry out additional tasks as assigned by management.

⛳️ Requirements

• High School Diploma/GED is required.

• A Bachelor's degree in Nursing is preferred or relevant experience may substitute for the degree.

• A minimum of two (2) years of clinical experience is required.

• At least three (3) years' experience in the health care delivery system/industry is required.

• A minimum of two (2) years' experience with health care payer systems is required.

• An active unrestricted RN License is required; NJ License is preferred.

• A valid Driver's License and Insurance are required.

• Proficiency in personal computers and Windows-based software, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook.

• Working knowledge of case/care/disease management principles.

• Familiarity with utilization, case, and/or disease management processes.

• Understanding of utilization management principles.

• Basic knowledge of health care contracts and benefit eligibility requirements.

• Knowledge of hospital structures and payment systems is required.

• Bi-lingual proficiency is preferred.

• Travel up to 25% may be necessary.

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

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous PTO.

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.