Horizon Blue Cross Blue Shield of New Jersey · 1 day ago
RN II
United States
Full-time
Remote
Entry, Mid Level
$79K/yr - $106K/yr
2+ years expHorizon Blue Cross Blue Shield of New Jersey empowers members to achieve their best health and has been a leader in health solutions for over 90 years. The RN II position is responsible for performing nursing duties to ensure appropriate levels of care, mentoring new staff, and coordinating services across various healthcare settings.
Health Care
Responsibilities
Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay
Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided
Coordinates and assists in implementation of plan for members
Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care
Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided
Encourages member participation and compliance in the case/disease management program efforts
Documents accurately and comprehensively based on the standards of practice and current organization policies
Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care
Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
Serves as mentor/trainer to new RN's and other staff as needed
Acts as subject matter expert for respective area for projects
May assume leadership type activities in team leads absence
Represent clinical teams within committee meetings
Present reports required at committee meetings
Subject matter expert for user acceptance testing for medical management system
Outreaches to members identified by Horizon as needing Clinical Advocate services
Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment
Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques
Becomes knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language
Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
Focuses on whole person approach, by eliminating 'homework' or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional
Qualification
Required
High School Diploma/GED required
Requires a minimum of two (2) years clinical experience
Requires minimum of two (2) years' experience with health care payer experience
Active Unrestricted NJ RN License or active Compact License Required
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook)
Requires knowledge of hospital structures and payment systems
Requires working knowledge of case/care/disease management principles
Requires working knowledge of operations of utilization, case and/or disease management processes
Requires knowledge of health care contracts and benefit eligibility requirements
Requires mentoring knowledge on the operations of utilization/case/disease management
Adaptability/Flexibility
Analytical
Compassion
Interpersonal & Client Relationship Skills
Information/Knowledge Sharing
Judgment
Listening
Planning/Priority Setting
Problem Solving
Team Player
Time Management
Written/Oral Communication & Organizational Skills
Preferred
Bachelor degree preferred or relevant experience in lieu of degree
CCM certification preferred
Experience in active listening and motivational interviewing strongly preferred
Requires ability to be an empathetic critical thinker
Requires excellent communication and organizational skills and a high tolerance for ambiguity
Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization
Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills
Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Company
Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Gary St. Hilaire
President & Chief Executive Officer
Recent News
2026-01-06
2025-12-29
2025-12-25
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