Horizon Blue Cross Blue Shield of New Jersey is hiring an RN II Case Manager for Pediatric Oncology. In this role, you will apply your clinical expertise to ensure the appropriate level and continuity of care for members, serving as a mentor and subject matter expert. You'll be part of New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.
What You'll Do
- Assess patient's clinical need against established guidelines to ensure inpatient care and length of stay are medically appropriate.
- Evaluate the necessity, appropriateness, and efficiency of medical services and procedures.
- Coordinate and assist in implementing care plans for members.
- Monitor and coordinate services rendered outside of the network or local area, negotiating fees as appropriate.
- Coordinate with patient, family, physician, hospital, and other external parties regarding the appropriateness of care from diagnosis to outcome.
- Coordinate the delivery of high-quality, cost-effective care supported by clinical practice guidelines.
- Monitor medical care activities and outcomes for appropriateness and effectiveness.
- Advocate for the member and family across various sites to coordinate resource utilization.
- Encourage member participation and compliance in case and disease management programs.
- Document accurately based on standards of practice and organizational policies.
- Interact with multidisciplinary teams telephonically or in person for continuity of care.
- Understand fiscal accountability and its impact on resource utilization and self-care outcomes.
- Evaluate care by problem solving, analyzing variances, and participating in quality improvement programs.
- Serve as mentor and trainer to new RNs and other staff.
- Act as a subject matter expert for projects.
- May assume leadership activities in a team lead's absence.
- Represent clinical teams within committee meetings and present required reports.
- Serve as subject matter expert for user acceptance testing for the medical management system.
- Outreach to members identified as needing Clinical Advocate services.
- Apply critical thinking and clinical expertise to maximize outcomes in a fast-paced environment.
- Build trusting relationships with members and families using Motivational Interviewing techniques.
- Explain employer-sponsored medical benefits, claims, and care coordination in plain language.
- Advocate for members consistently throughout their healthcare journey.
- Focus on a whole person approach, addressing overall well-being.
What We're Looking For
- High School Diploma/GED.
- Minimum of two (2) years clinical experience.
- Minimum of two (2) years' experience with a health care payer.
- Active Unrestricted NJ RN License or active Compact License.
- Proficiency with personal computers and supporting software in a Windows environment, including MS Office (Word, Excel, PowerPoint, Outlook).
- Knowledge of hospital structures, payment systems, and health care contracts.
- Working knowledge of case, care, and disease management principles and operations.
- Mentoring knowledge on utilization, case, and disease management operations.
- Adaptability, analytical skills, compassion, and strong interpersonal skills.
- Information sharing, judgment, listening, planning, and problem-solving skills.
- Team player with strong time management and written/oral communication skills.
- Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
Nice to Have
- Bachelor's degree or relevant experience in lieu of degree.
- CCM certification.
- Experience in active listening and motivational interviewing.
- Current or previous experience in pediatric oncology for bedside care or case management.
Technical Stack
- Personal computers, Windows based environment
- MS Office products (Word, Excel, PowerPoint, Outlook)
- Intranet and internet applications
Benefits & Compensation
- Compensation: $79,100 - $105,945
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Work Mode
This is a remote position. Candidates must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer.
