RN I - Clinical Authorizations job at Horizon Blue Cross Blue Shield of New Jersey in Trenton

Horizon Blue Cross Blue Shield of New Jersey is hiring RN I - Clinical Authorizations on Sat, 20 Oct 2012 03:37:16 GMT. This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. 1. Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the...

RN I - Clinical Authorizations

Location: Trenton New Jersey

Description: Horizon Blue Cross Blue Shield of New Jersey is hiring RN I - Clinical Authorizations right now, this job will be placed in New Jersey. Further informations about this job opportunity kindly read the description below. This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the conti! nuum of care. Performs duties and types of care management as assigned by management.

1. Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.

2. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.

3. Coordinates and assists in implementation of plan for members.

4. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

5. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
6. Monitors patient's medical care activities, regardless o! f the site of service, and outcomes for appropriateness and effectiveness.

7. Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

8. Encourages member participation and compliance in the case/disease management program efforts.

9. Documents accurately and comprehensively based on the standards of practice and current organization policies.

10. 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.

11. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

12. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

13. Completes other assigned functions as requested by mana! gement.

Education/Experience

1. Requires an associates or bachelors degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.

2. Requires a minimum of two (2) years clinical experience.

Additional licensing, certifications, registrations

1. Requires an active New Jersey Registered Nurse License.

Knowledge

• Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.
• Prefers working knowledge of case/care management principles.
• Prefers working knowledge of principles of utilization management.
• Prefers basic knowledge of health care contracts and benefit eligibility requirements.
• Prefers knowledge of hospital structures and payment systems.
Skills and Abilities


• Analytical
• Compass! ion
• Interpersonal & Client Relationship Skills
• Judgment
• Listening
• Planning/Priority Setting
• Problem Solving
• Team Player
• Time Management
• Written/Oral Communication & Organizational Skills
Travel (If Applicable)

Disclaimer

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.
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If you were eligible to this job, please email us your resume, with salary requirements and a resume to Horizon Blue Cross Blue Shield of New Jersey.

If you interested on this job just click on the Apply button, you will be redirected to the official website

This job starts available on: Sat, 20 Oct 2012 03:37:16 GMT





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