September 01, 2016
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Horizon Blue Cross Blue Shield of New Jersey - Trenton, NJ

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Job Description

Job Summary:

This field based position is responsible for performing assessments of managed long term support and service program members using established guidelines to ensure appropriate level of care and develop a member centric plan of care.


* Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members' needs.

* Evaluates the necessity, appropriateness and efficiency of managed long term care and supportive services provided.

* Develops, coordinates and assists in implementation of members individualized plan of care.

* 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 member'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 managed long term care and support and services program.

* 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


* Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel,PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.

* Working knowledge of case/care management principles.

* Working knowledge of principles of utilization management.

* Prefers basic knowledge of health care contracts and benefit eligibility requirements.

* Prefers knowledge of hospital structures and payment systems.

Skills and Abilities:

* Analytical

* Compassionate

* Interpersonal & Client Relationship Building Skills

* Sound Decision Making

* Active Listening

* Organization/Planning/Priority Setting

* Problem Solving/Critical Thinking

* Team Player

* Time Management

* Written/Oral Communication Skills (Bi-lingual preferred)


* Requires an associates or bachelor s degree (or higher) in nursing and/or accredited diploma nursing school.

* Requires a minimum of two (2) years clinical experience.

Additional licensing, certifications, registrations:

* Requires an active New Jersey Registered Nurse License.

Travel (If Applicable):

* This is a field based position, daily local travel is required.

* Requires a car with valid New Jersey State License and Insurance.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.


Bachelors, Associates

Job Level
Individual Contributor

--Horizon NJ Health

Job Type
Full Time

Trenton, NJ