RN II – Primary Nurse Care

• Perform RN duties for the Primary Nurse population using established guidelines to ensure appropriate level of care.
• Plan transitions to the continuum of care and develop member-centric plans of care.
• Outreach to high-risk members and engage members in preventative care opportunities and screenings.
• Assess members’ clinical needs against established guidelines and benefit structures.
• Facilitate responses to gaps in care and direct high-risk members to appropriate care settings.
• Evaluate the necessity, appropriateness, and efficiency of medical services and procedures for acute and chronic needs.
• Develop, coordinate, and assist in implementing individualized plans of care and identify barriers to self-management and optimal wellness.
• Coordinate with members, families, physicians, hospitals, and external customers regarding appropriateness of care.
• Coordinate high-quality, cost-effective care across the continuum, including transitional care.
• Monitor members’ medical care activities and outcomes for appropriateness and effectiveness.
• Advocate for members and families across care sites to coordinate resource utilization and evaluate services.
• Encourage member participation and compliance in case/disease management programs.
• Document accurately and comprehensively according to standards and organizational policies.
• Communicate with multidisciplinary teams telephonically and/or in person.
• Evaluate care, analyze variances, and participate in quality improvement programs.
• Mentor and train new RNs and other staff as needed.
• Present clinical cases during audits conducted by external review organizations.
• Perform other duties as assigned by management.
• Positions involving ASO accounts may require some travel for on-site availability.

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.
• Requires a minimum of three (3) years' experience in the health care delivery system/industry.
• Experience with both acute and chronic conditions preferred.
• 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.
• Proficiency in personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook.
• Working knowledge of case/care/disease management principles.
• Working knowledge of utilization, case and/or disease management processes.
• Working knowledge of utilization management principles.
• Basic knowledge of health care contracts and benefit eligibility requirements.
• Knowledge of hospital structures and payment systems.
• Bi-lingual proficiency preferred.
• Skills in adaptability/flexibility, analysis, compassion, information/knowledge sharing, interpersonal and client relationship management, sound decision making, active listening, organization planning/priority setting, problem solving/critical thinking, teamwork, time management, and written/oral communications.

Core Competencies

Demonstrates expertise in care coordination, member advocacy, and clinical assessment, with a strong focus on developing and implementing individualized care plans. Proficient in utilizing case management principles and collaborating with multidisciplinary teams to ensure high-quality, cost-effective care.

Highest-signal resume keywords

• Active Unrestricted RN License
• Clinical Experience
• Health Care Payer Experience
• Utilization Management Principles
• Case Management Principles

ATS Optimization Keywords

Hard Skills

• Clinical Assessment
• Care Coordination
• Individualized Care Plans
• Utilization Management
• Disease Management
• Health Care Contracts Knowledge
• Windows Based Software Proficiency
• MS Office Proficiency
• Documentation Standards
• Quality Improvement Participation

Soft Skills

• Interpersonal Skills
• Problem Solving
• Time Management
• Teamwork
• Active Listening

Certifications & Qualifications

• RN License
• NJ License
• Compact License
• Valid Driver's License

Industry Keywords

• Health Care Delivery System
• Acute Conditions
• Chronic Conditions
• Member-Centric Care
• Transitional Care

Tools & Technologies

• MS Word
• MS Excel
• MS PowerPoint
• Microsoft Outlook