RN II, Commercial Risk Adjustment

Job not on LinkedIn

🔥 0 minutes ago

🦌 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 18%

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

• Perform care management duties targeting high-risk members within commercially risk-adjusted populations • Assess high-risk members' health status annually and engage members in preventative care opportunities and screenings • Facilitate navigation of high-risk members to appropriate care settings and annual wellness visits • Coordinate transitions from RAM RN to care management RN • Encourage member participation and compliance in case/disease management programs • Collaborate with RAM Business Analysts and Manager to engage at-risk members • Deploy clinical engagement strategies using RAM insights, member outreach calls, and retail pharmacy information • Develop ad-hoc clinical outreach strategies and interpret RAM analytical reports • Develop and expand member outreach initiatives, including potential physician or pharmacy visits • Assess clinical needs against established guidelines and develop, coordinate, and assist with individualized plans of care • Evaluate medical service necessity, appropriateness, and efficiency • Coordinate with members, families, physicians, hospitals, and external customers across the continuum of care • Monitor medical care activities and outcomes for appropriateness and effectiveness • Advocate for members and families across care sites • Document accurately and comprehensively according to standards and policies • Evaluate care, analyze variances, and participate in quality improvement programs • 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 • 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 • Proficiency in personal computers and Windows-based software, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook • Working knowledge of case/care/disease management principles • Working knowledge of utilization, case and/or disease management processes • Working knowledge of utilization management principles • Basic knowledge of health care contracts and benefit eligibility requirements • Knowledge of hospital structures and payment systems • Bi-lingual proficiency preferred • Travel up to 25% may be required • Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

🏖️ Benefits

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