Care Manager I, Specialty Programs
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Job Description
Care Manager coordinating specialty-population care and transitions for Horizon Blue Cross Blue Shield of New Jersey. Implementing cost-effective interventions and monitoring member outcomes.
Responsibilities:
- Perform care coordination duties using established guidelines to ensure appropriate level of care and plan transitions to the continuum of care for specialty populations.
- Implement interventions to ensure efficient utilization of benefits.
- Assess members’ clinical needs against established guidelines and standards.
- Implement high-quality, cost-effective care based on customized population models and clinical practice guidelines.
- Partner with members/families, physicians, and healthcare teams to meet member needs.
- Advocate for members across sites and coordinate resource utilization.
- Set priorities, plan, organize, and implement goal-directed interventions supporting self-care outcomes and transition to independent status.
- Ensure care for mandated non-compliant members through utilization monitoring.
- Document accurately and comprehensively according to practice standards and organization policies.
- Evaluate care, solve problems, analyze variances, and participate in quality improvement.
- Monitor care activities and outcomes for appropriateness and effectiveness.
- Consult internal stakeholders on complex cases and escalate to internal physician resources as appropriate.
- Complete other assigned functions as requested by management.
Requirements:
- Requires a license as an RN, or Bachelor degree in social work, health or behavioral science.
- Requires a minimum of three (3) years’ experience serving members with special needs.
- Graduate level degree in Social Work or Health and Behavioral Science preferred.
- Requires strong knowledge of the standards of practice for case managers.
- Requires strong knowledge of managed care principles.
- Requires strong knowledge of specialty population, as applicable.
- Requires strong organizational skills.
- Requires strong oral and written communication skills.
- Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.).
- Requires good problem solving and conflict resolution skills.
- Requires a car with valid New Jersey State License and Insurance for certain positions.
- Employees must live 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
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