RN II – Primary Nurse Care, Case Management

This is a fully remote position, open to applicants in New Jersey.

📋 Description

• Evaluate the clinical needs of members against established guidelines and standards to confirm that the services delivered are medically suitable for their needs and comply with the benefit structure.

• Facilitate the response to care gaps and identify high-risk members, directing them to appropriate care settings for annual wellness visits, including collaboration with their treating providers.

• Assess the necessity, appropriateness, and efficiency of medical services and procedures for both acute and chronic healthcare needs.

• Develop, coordinate, and aid in the execution of personalized care plans for members while identifying barriers to self-management and optimal wellness.

• Collaborate with members, families, physicians, hospitals, and other external customers regarding the appropriateness of care from diagnosis to outcome.

• Oversee the delivery of high-quality, cost-effective care in line with clinical practice guidelines established by the plan, addressing the entire continuum of care including transitional care.

• Monitor members' medical care activities, regardless of the service site, ensuring appropriateness and effectiveness of outcomes.

• Advocate for members and families across various sites to coordinate resource utilization and evaluate the services provided.

• Promote member participation and adherence to case and disease management program initiatives.

• Accurately and comprehensively document activities following standards of practice and current organizational policies.

• Interact and communicate with multidisciplinary teams both telephonically and/or in person, aiming for continuity and efficiency while managing the member's care continuum.

• Analyze care effectiveness by problem-solving, identifying variances, and engaging in quality improvement programs to enhance member outcomes.

• Serve as a mentor and trainer for new RNs and other staff as needed.

• Present clinical cases during audits conducted by external review organizations.

• Perform additional duties as assigned by management.

⛳️ Requirements

• High School Diploma/GED is required.

• A Bachelor's degree is preferred, or relevant experience may be considered in lieu of a degree.

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

• Experience with both acute and chronic conditions is preferred.

• At least three (3) years of experience in the healthcare delivery system or industry is required.

• Strong preference for candidates with healthcare payer experience.

• An active, unrestricted RN License is required; NJ License and/or Compact License is necessary.

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

• Proficiency in personal computer use and supporting software in a Windows environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook.

• A working knowledge of case, care, and disease management principles is necessary.

• Familiarity with the operations of utilization, case, and/or disease management processes is required.

• Requires working knowledge of utilization management principles.

• Basic understanding of healthcare contracts and benefit eligibility requirements is essential.

• Knowledge of hospital structures and payment systems is required.

🏝️ Benefits

• Comprehensive health benefits including Medical, Dental, and Vision.

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.