RN II- Utilization Review
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POST DATE 8/25/2016
END DATE 10/8/2016
JOB DESCRIPTIONJob Summary:
This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed.
* 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.
* Completes other assigned functions as requested by management.
* 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 Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.
* 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.
Skills and Abilities:
* Interpersonal & Client Relationship Skills
* Information/Knowledge Sharing
* Planning/Priority Setting
* Problem Solving
* Team Player
* Time Management
* Written/Oral Communication & Organizational Skills
* Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
* Requires a minimum of two (2) years clinical experience.
* Requires minimum of three (3) years experience in the health care delivery system/industry.
* Requires minimum of two (2) years experience with health care payer experience.
Additional licensing, certifications, registrations:
* Requires an active New Jersey Registered Nurse License.
* Prefers pending or obtained certification in case management, Certified Diabetes Educator (CDE), or other applicable clinical specialties.
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.