RN II – Primary Nurse Care, Case Management

Responsibilities

• Assess member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure
• Facilitate response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider
• Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs
• Develop, coordinate and assist in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness
• Coordinate with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
• Coordinate the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care
• Monitor member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
• Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided
• Encourage member participation and compliance in the case/disease management program efforts
• Document accurately and comprehensively based on the standards of practice and current organization policies
• Interact and communicate with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care
• Evaluate care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
• Serve as mentor/trainer to new RN's and other staff as needed
• Present clinical cases during audits conducted by external review organizations
• Perform other duties as assigned by management

Requirements

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree
• Minimum of two (2) years clinical experience
• Experience with both acute and chronic conditions preferred
• Minimum of three (3) years' experience in the health care delivery system/industry
• Health care payer experience strongly preferred
• Active Unrestricted RN License Required; NJ License required and/or Compact License
• Requires a valid Driver's License and Insurance
• Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook
• Working knowledge of case/care/disease management principles
• Working knowledge of operations of utilization, case and/or disease management processes
• Requires working knowledge of principles of utilization management
• Basic knowledge of health care contracts and benefit eligibility requirements
• Knowledge of hospital structures and payment systems.

Core Competencies

Demonstrates expertise in clinical assessment, care coordination, and case management, ensuring the delivery of high-quality, cost-effective care aligned with established guidelines. Proficient in collaborating with multidisciplinary teams and advocating for member needs throughout the continuum of care.