RN II, Primary Nurse Care – Case Manager

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

📋 Description

• Evaluates members' clinical needs against established guidelines and standards to confirm that the services rendered are medically suitable for the members and aligned with the benefit structure.

• Facilitates responses to identified care gaps and high-risk members by directing them to appropriate care settings for annual wellness visits, including collaboration with the treating provider.

• Assesses the necessity, appropriateness, and efficiency of medical services and procedures for both acute and chronic health care needs.

• Develops, coordinates, and aids in the implementation of personalized care plans for members while identifying barriers to self-management and achieving optimal wellness.

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

• Oversees the delivery of high-quality, cost-effective care supported by clinical practice guidelines established by the plan, covering the entire continuum of care, including transitional care.

• Monitors members' medical care activities, irrespective of the service site, and evaluates outcomes for appropriateness and effectiveness.

• Advocates for members and their families across various sites to coordinate resource utilization and assess the services provided.

• Promotes member participation and adherence in case and disease management programs.

• Accurately and comprehensively documents according to practice standards and current organizational policies.

• Engages and communicates with multidisciplinary teams, either by phone or in person, aiming for continuity and efficiency as members are managed throughout the continuum of care.

• Evaluates care by solving problems, analyzing variances, and participating in quality improvement initiatives to enhance member outcomes.

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

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

⛳️ Requirements

• High School Diploma or GED is required.

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

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

• A minimum of three (3) years of experience in the health care delivery system or industry is required.

• Experience with both acute and chronic conditions is preferred.

• 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 using personal computers and supporting software in a Windows-based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook is required.

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

• A working knowledge of the operations involved in utilization, case, and/or disease management processes is required.

• A solid understanding of the principles of utilization management is necessary.

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

• Familiarity with hospital structures and payment systems is required.

• Bilingual proficiency is preferred.

🏝️ 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.