Responsibilities: Assesses patients 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. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Coordinates and assists in implementation of plan for members. 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. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patients 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. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Serves as mentor trainer to new RNs and other staff as needed. Acts as subject matter expert for respective area for projects. May assume leadership type activities in team leads absence. Represent clinical teams within committee meetings. Present reports required at committee meetings. Subject matter expert for user acceptance testing for medical management system.

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.

Education - Experience: High School Diploma or GED required. Bachelor degree preferred or relevant experience in lieu of degree. Requires a minimum of two 2 years clinical experience. Requires minimum of two 2 years experience with health care payer experience. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or active Compact License Required.

Knowledge: Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications. Requires knowledge of hospital structures and payment systems. Requires working knowledge of case, care, disease management principles. Requires working knowledge of operations of utilization, case and or disease management processes. Requires knowledge of health care contracts and benefit eligibility requirements. Requires mentoring knowledge on the operations of utilization, case, disease management.