RN II, Commercial Risk Adjustment

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🕒 Setembro 25

🦌 Connecticut, New Jersey, +2 estados a mais – Remoto

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $79.100 - $105.945 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

🎲 Riscos

👻 Score fantasma 23%

O que significa: quão provável esta vaga está aberta sem contratação ativa.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Como pontuamos: tempo em aberto, republicações, vagas abertas vs tamanho do time, rapidez para fechar vagas, e se o salário está divulgado.Observação: é uma estimativa de dados públicos, não um julgamento da empresa. Vagas reais podem ter pontuação alta, então use como uma dica, não como um fato.

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Horizon Connect @ Wall BCBSNJ

SiteLinkedInTodas as Vagas

2 - 10 funcionários

⚕️ Seguro de Saúde

🏥 Saúde

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ é uma presença no LinkedIn ou programa/escritório local associado ao Horizon Blue Cross Blue Shield de New Jersey (BCBSNJ). Com base no nome e no contexto, parece estar conectado às operações de seguro de saúde do Horizon BCBSNJ e ao alcance local ou envolvimento de membros/provedores na área de Wall, NJ. As informações disponíveis publicamente são limitadas e consistem principalmente na interface do site do LinkedIn em vez de um perfil da empresa, então essa descrição é conservadora e baseada na afiliação indicada pelo nome.

Descrição

• Facilitate navigation of high-risk members to appropriate settings of care for annual wellness visits, including outreach to members, providers and retail pharmacies. • Coordinate member transitions from RAM RN to care management RN based on CM program qualification and member commitment. • Encourage member participation and compliance in case/disease management programs. • Work with RAM Business Analysts and Manager to engage at-risk members in commercially risk-adjusted markets. • Deploy clinical engagement strategies using insights from RAM, member outreach calls and retail pharmacies. • Develop ad-hoc clinical outreach strategies for highest-risk members and interpret RAM analytical reports. • Develop and expand member outreach initiatives, including driving potential physician or pharmacy visits. • Assess clinical needs against guidelines and benefit structures; develop, coordinate and help implement individualized plans of care. • Evaluate the necessity, appropriateness and efficiency of medical services and procedures. • Coordinate with members, families, physicians, hospitals and external customers regarding appropriateness of care. • Coordinate high-quality, cost-effective care across the continuum, including transitional care, with multidisciplinary teams. • Monitor medical care activities and outcomes for appropriateness and effectiveness. • Advocate for members and families across care sites to coordinate resource utilization and evaluate services. • Document accurately and comprehensively according to practice standards and organizational policies. • Evaluate care, analyze variances and participate in quality improvement to enhance member outcomes. • Mentor/train new RNs and other staff as needed. • Perform other duties assigned by management.

🎯 Requisitos

• High School Diploma/GED required. • Bachelor degree in Nursing preferred or relevant experience in lieu of degree. • Requires a minimum of two (2) years clinical experience. • Prefer experience with the elderly, frail and those with chronic conditions. • Requires a minimum of three (3) years' experience in the health care delivery system/industry. • Requires a minimum of two (2) years' experience with health care payer experience. • Active Unrestricted RN License Required; NJ License Preferred. • Requires a valid Driver's License and Insurance. • Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook. • Prefers knowledge in the use of intranet and internet applications. • Requires working knowledge of case/care/disease management principles. • Requires working knowledge of operations of utilization, case and/or disease management processes. • Requires working knowledge of principles of utilization management. • Requires basic knowledge of health care contracts and benefit eligibility requirements. • Requires knowledge of hospital structures and payment systems. • Prefers understanding of fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. • Bi-lingual proficiency preferred. • Travel up to 25%. • Travel primarily within State of NJ may be required; occasional travel in the tri-state areas may also be required. • Positions for the exchange population are field based and will require travel.

🏖️ Benefícios

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement