RN II, Commercial Risk Adjustment

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 will perform care management duties specifically targeting high risk members within commercially risk adjusted populations to enhance the deployment of commercial risk adjustment tactics. This position will work closely with the Risk Adjustment Management (RAM) function, including the RAM Manager & RAM Business Analysts to assess the health status of high risk members on an annual basis and will work to engage these members in preventative care opportunities & screenings, including opportunities in retail settings if possible. This position is responsible for performing RN duties for members in commercially risk adjusted products , using established guidelines to ensure appropriate level of care, as well as, planning for the transition to the continuum of care and developing a member centric plan of care. When appropriate, there will be responsibility for ensuring members are engaged for annual wellness visits. This position will leverage analytical insights from RAM to create clinical strategies that drive encounters for high-risk members that support commercial risk adjustment initiatives. This position serves as a mentor/trainer to new RN's and other staff as needed. Positions involving the commercially risk adjusted population may require travel. What You'll Do Facilitates the navigation of high risk members to appropriate settings of care for annual wellness visits, including outreach to members, providers and retail pharmacies. Coordinates transition of member from RAM RN to care management RN based qualification for CM program and member commitment to participation. Encourages member participation and compliance in the case/disease management program efforts Works closely with RAM Business Analyst and Manager to engage at-risk members in commercially risk adjusted markets. Deploys clinical engagement strategy to integrate clinical insights from multiple information sources, including RAM, member outreach calls, or retail pharmacies. Performs ad-hoc clinical outreach strategy development to highest risk members to support commercial risk adjustment tactics. Interprets analytical reports as developed by the RAM team to deploy clinical outreach strategy. Develops & expands member outreach initiatives to case / disease management eligible members, including driving potential physician or pharmacy visits. 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 benefit structure, and develops, coordinates and assists in implementation of individualized plan of care for members. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Develops, coordinates and assists in implementation of individualized plan of care for members. 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 and communicates with multi-disciplinary teams striving for continuity and efficiency as the member is managed along the continuum of 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. Documents accurately and comprehensively based on the standards of practice and current organization policies. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Performs other duties as assigned by management. What You Bring Education/Experience: 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. Additional licensing, certifications, registrations: Active Unrestricted RN License Required; NJ License Preferred. Requires a valid Driver's License and Insurance. Knowledge: 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 uti