RN II – Pediatrics Case Manager

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🔥 2 minutes ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $79.1k - $105.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👔 Manager

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NJM Insurance Group

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1913

Insurance

NJM Insurance Group is a well-established insurance provider offering a range of personal and commercial insurance products. Their services include auto, homeowners, renters, condo, commercial auto, and business insurance, with a focus on exceptional customer satisfaction and claims experience. NJM is recognized for its outstanding auto claims experience by J. D. Power and is committed to serving customers in states like Connecticut, Maryland, New Jersey, Ohio, and Pennsylvania. The company prides itself on being straightforward and customer-focused, without jingles or mascots, offering trusted insurance solutions and multiple discount opportunities for various policies.

📋 Description

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure. • Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider. • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs. • Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness. • Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. • Monitors member'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. • Encourages member participation and compliance in the case/disease management program efforts.

🎯 Requirements

• Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. • Requires a minimum of two (2) years clinical experience. • Experience with both acute and chronic conditions preferred. • Requires a minimum of three (3) years' experience in the health care delivery system/industry. • Experience with health care payer experience strongly preferred. • 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, and PowerPoint) and Microsoft Outlook. • 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. • Bi-lingual proficiency preferred.

🏖️ Benefits

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