RN II, Commercial Risk Adjustment
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Job Description
RN managing high-risk members and commercial risk adjustment care for Horizon Blue Cross Blue Shield of New Jersey. Coordinating outreach, wellness visits, utilization management, and individualized care plans.
Responsibilities:
- Perform care management duties targeting high-risk members within commercially risk-adjusted populations
- Assess high-risk members' health status annually and engage members in preventative care opportunities and screenings
- Facilitate navigation of high-risk members to appropriate care settings and annual wellness visits
- Coordinate transitions from RAM RN to care management RN
- Encourage member participation and compliance in case/disease management programs
- Collaborate with RAM Business Analysts and Manager to engage at-risk members
- Deploy clinical engagement strategies using RAM insights, member outreach calls, and retail pharmacy information
- Develop ad-hoc clinical outreach strategies and interpret RAM analytical reports
- Develop and expand member outreach initiatives, including potential physician or pharmacy visits
- Assess clinical needs against established guidelines and develop, coordinate, and assist with individualized plans of care
- Evaluate medical service necessity, appropriateness, and efficiency
- Coordinate with members, families, physicians, hospitals, and external customers across the continuum of care
- Monitor medical care activities and outcomes for appropriateness and effectiveness
- Advocate for members and families across care sites
- Document accurately and comprehensively according to standards and policies
- Evaluate care, analyze variances, and participate in quality improvement programs
- Mentor/train new RNs and other staff as needed
- Perform other duties assigned by management
Requirements:
- High School Diploma/GED required
- Bachelor degree in Nursing preferred or relevant experience in lieu of degree
- Requires a minimum of two (2) years clinical experience
- Requires a minimum of three (3) years' experience in the health care delivery system/industry
- Requires a minimum of two (2) years' experience with health care payer experience
- Active Unrestricted RN License Required; NJ License Preferred
- Requires a valid Driver's License and Insurance
- 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
- Working knowledge of utilization, case and/or disease management processes
- Working knowledge of utilization management principles
- Basic knowledge of health care contracts and benefit eligibility requirements
- Knowledge of hospital structures and payment systems
- Bi-lingual proficiency preferred
- Travel up to 25% may be required
- Horizon BCBSNJ 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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