MLTSS Field RN/Registered Nurse I-Passaic County, NJ

Horizon Blue Cross Blue Shield of New Jersey
US - New Jersey - Elizabeth
January 31, 2025
Medical

Summary:

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 structure
Evaluates the necessity, appropriateness and efficiency of service provided
Develops, coordinates and assists in implementation of services to meet the needs of the members
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
Refers members to MLTSS when appropriate
Educates members on the availability of SNP if appropriate
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

Disclaimer: 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 this job.

Education/Experience:

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
A minimum of two (2) years clinical experience is preferred.

Additional licensing, certifications, registrations:

Active Unrestricted NJ RN License Required.

Knowledge:

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).

Travel :

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

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.

Read the full job description and apply online on the recuiter's web-site

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