RN I, PCA/MDC/SNP - Specialty Chronic Condition Plan

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role

This 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.

What You'll Do

• Clinical Assessment & Service Authorization
• Conduct comprehensive member assessments using established guidelines and assessment tools to determine appropriate levels of care and service needs.
• Evaluate the necessity, appropriateness, and effectiveness of healthcare services and procedures.
• Assess clinical needs and support authorization of services based on established standards and program requirements.
• Monitor healthcare utilization and member outcomes to ensure services remain appropriate and effective.
• Care Coordination & Continuum of Care Management
• Coordinate and assist with the implementation of individualized care plans.
• Facilitate delivery of high-quality, cost-effective care across the continuum of care.
• Coordinate services among providers, healthcare facilities, family members, and community resources.
• Monitor and coordinate services delivered outside of the local area or network when appropriate.
• Support seamless transitions between healthcare settings and levels of care.
• Member Advocacy & Engagement
• Advocate for members and families to ensure access to appropriate healthcare services and resources.
• Encourage member participation and compliance with care management and disease management programs.
• Help members navigate healthcare services and address barriers to care.
• Promote positive health outcomes through education, support, and ongoing engagement.
• Collaboration & Communication
• Partner with physicians, hospitals, caregivers, and multidisciplinary teams to support coordinated care delivery.
• Build strong relationships with internal and external stakeholders to enhance the member experience.
• Communicate effectively to ensure continuity, quality, and efficiency of care.
• Participate in discussions and initiatives that improve coordination among care teams.

Disclaimer:

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.