This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized.

Responsibilities

• :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 structur
• eEvaluates the necessity, appropriateness and efficiency of service provide
• dDevelops, coordinates and assists in implementation of services to meet the needs of the member
• sCoordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcom
• eCoordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of car
• eMonitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectivenes
• sAdvocates for the member/family among various sites to coordinate resource utilization and evaluation of services provide
• dRefers members to MLTSS when appropriat
• eEducates members on the availability of SNP if appropriat
• eDocuments accurately and comprehensively based on the standards of practice and current organization policie
• sInteracts 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 car
• eUnderstands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcome
• sEvaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcome
• sCompletes other assigned functions as requested by managemen
• tPerforms duties as assigned by managemen

t
Education/Experienc

• e:High School Diploma/GED require
• d.Bachelor's degree preferred or relevant experience in lieu of degre
• e.A minimum of two (2) years clinical experience is preferre

d.
Additional licensing, certifications, registratio

• ns:Active Unrestricted NJ RN License Requir

ed.
Knowle

• dge: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 applicati
• ons.Working knowledge of case/care management princip
• les.Working knowledge of principles of utilization managem
• ent.Prefers basic knowledge of health care contracts and benefit eligibility requireme
• nts.Prefers knowledge of hospital structures and payment syst

ems.
Skills and Abili

• ties:Analy
• ticalCompassi
• onateInterpersonal & Client Relationship Building S
• killsSound Decision M
• akingActive List
• eningOrganization/Planning/Priority Se
• ttingProblem Solving/Critical Thi
• nkingTeam P
• layerTime Manag
• ementWritten/Oral Communication Skills (Bi-lingual prefer

red).
Tr

avel :This is a field based position, daily local travel is req

uired.
Addendum: RN 1.5. Completes NJ Choice Home Care Assessments for new referrals to MLTSS. Assists with MLTSS case management when necessary, to cover for FMLA or to maintain MLTSS caseloads below contractual obligations. Provide support when needed to MLTSS care management staff, including but not limited to annual assessment, 90 day and/or post hospital

visits.
Dis

claimer:This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to th

is job.
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. Horizon will consider reasonable accommodation requests as part of the recruiting and hirin