Registered Nurse in Trenton, NJ

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

Responsibilities:

• 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.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
• 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 patient'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.
• Encourages member participation and compliance in the case/disease management program efforts.

Qualifications:

• Requires an associate’s or bachelor’s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
• Requires a minimum of two (3) years clinical experience. Additional licensing, certifications, registrations
• Working knowledge of case/care management principles and utilization management.
• Prefers basic knowledge of health care contracts and benefit eligibility requirements.
• Prefers knowledge of hospital structures and payment systems. 

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