RN II, Commercial Risk Adjustment

. Perform care management duties targeting high-risk members within commercially risk-adjusted populations .

Posted 9/25/2026full-timeRemote • United StatesMid-LevelSenior💰 $79,100 - $105,945 per yearWebsite

Key responsibilities & impact

Perform care management duties targeting high-risk members within commercially risk-adjusted populations
Assess high-risk members' health status annually and engage members in preventative care opportunities and screenings
Facilitate navigation of high-risk members to appropriate care settings and annual wellness visits
Coordinate transitions from RAM RN to care management RN
Encourage member participation and compliance in case/disease management programs
Collaborate with RAM Business Analysts and Manager to engage at-risk members
Deploy clinical engagement strategies using RAM insights, member outreach calls, and retail pharmacy information
Develop ad-hoc clinical outreach strategies and interpret RAM analytical reports
Develop and expand member outreach initiatives, including potential physician or pharmacy visits
Assess clinical needs against established guidelines and develop, coordinate, and assist with individualized plans of care
Evaluate medical service necessity, appropriateness, and efficiency
Coordinate with members, families, physicians, hospitals, and external customers across the continuum of care
Monitor medical care activities and outcomes for appropriateness and effectiveness
Advocate for members and families across care sites
Document accurately and comprehensively according to standards and policies
Evaluate care, analyze variances, and participate in quality improvement programs
Mentor/train new RNs and other staff as needed
Perform other duties assigned by management

What you’ll need

High School Diploma/GED required
Bachelor degree in Nursing 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
Requires a minimum of two (2) years' experience with health care payer experience
Active Unrestricted RN License Required; NJ License Preferred
Requires a valid Driver's License and Insurance
Proficiency in personal computers and Windows-based software, including MS Office products (Word, Excel, 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
Travel up to 25% may be required
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Comp & perks