More Than 100 Years of Earning Trust
RN II – Primary Nurse Care
Location
New Jersey
Posted
1 day ago
Salary
$79.1K - $105.9K / year
Seniority
Mid Level
Job Description
RN II – Primary Nurse Care
NJM Insurance Group
• 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 • Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care • 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 • Documents accurately and comprehensively based on the standards of practice and current organization policies • Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care • Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes • Serves as mentor/trainer to new RN's and other staff as needed • Presents clinical cases during audits conducted by external review organizations • Performs other duties as assigned by management.
Job Requirements
- High School Diploma/GED required
- Bachelor degree preferred or relevant experience in lieu of degree
- 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 required and/or Compact License
- 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
- 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.
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
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