Horizon Blue Cross Blue Shield of New Jersey empowers its members to achieve their best health by driving innovations that improve healthcare quality, affordability, and member experience. The company is looking for a RN I, PCA/MDC/DSNP to perform assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.
Requirements
- Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs and aligned with benefit structure.
- Evaluates the necessity, appropriateness and efficiency of service provided.
- Develops, coordinates and assists in implementation of services to meet the needs of the members.
- 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.
- Refers members to MLTSS when appropriate.
- Educates members on the availability of SNP if appropriate.
- 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.
- Completes other assigned functions as requested by management.
- Performs duties as assigned by management.
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
