NJM Insurance Group

Compensation

Full Description

Job Description: • Assess member’s clinical need against establish guidelines and/or standards for specialty population-based members. • Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan. • Partner with the member/family, physician, and all members of the healthcare team to ensure the member’s needs are met, internal and external to this organization. • Advocate for the member among various sites to coordinate resource utilization. • Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status. • Ensure care for mandated non-compliant members through the monitoring of utilization. • Document accurately and comprehensively based on the standards of practice and current organization policies. • Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes. • Monitor member’s care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness. • Consult with internal stakeholders on complex cases and escalate as appropriate to internal physician resources. • Complete other assigned functions as requested by management. Requirements: • Requires a license as an RN, or Bachelor degree in social work, health or behavioral science • Graduate level degree in Social Work or Health and Behavioral Science preferred • Requires a minimum of three (3) years’ experience serving members with special needs • Requires strong knowledge of the standards of practice for case managers • Requires strong knowledge of managed care principles • Requires strong knowledge of specialty population, as applicable • Requires strong organizational skills • Requires strong oral and written communication skills • Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.) • Requires good problem solving and conflict resolution skills • Requires a car with valid New Jersey State License and Insurance for certain positions. Benefits: • Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement