RN II, Commercial Risk Adjustment

Job not on LinkedIn

🕒 September 25

🦌 Connecticut, New Jersey, +2 more states – Remote

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

💵 $79.1k - $105.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🎲 Risk

👻 Ghost score 21%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• 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.

🎯 Requirements

• 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.

🏖️ Benefits

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