Horizon Blue Cross Blue Shield of New Jersey

Role Description 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. The staffing requirements: Work week is 2 days during the week and 2 days on weekends, (4x10 shifts). The role trains 5 days 4-6 weeks M-F weekly, then goes to 4x10 schedule. 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. - 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 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. - 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. - Completes other assigned functions as requested by management. Qualifications - High School Diploma/GED required - Bachelor degree preferred or relevant experience in lieu of degree - Requires a minimum of two (2) years clinical experience. - Active Unrestricted NJ RN License or active Compact License Required. Requirements - RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Knowledge - Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). - Prefers knowledge in the use of intranet and internet applications. - Prefers working knowledge of case/care management principles. - Prefers working knowledge of principles of utilization management. - Prefers basic knowledge of health care contracts and benefit eligibility requirements. - Prefers knowledge of hospital structures and payment systems. Skills and Abilities - Analytical - Compassion - Interpersonal & Client Relationship Skills - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational Skills Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $70,500 - $94,395. This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.

Role Description This position is responsible for performing behavioral health 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. - Assesses patient's behavioral health 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 behavioral health 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 coordinates internally for negotiation of 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 behavioral health 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 behavioral health 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. - Completes other assigned functions as requested by management. Qualifications - Requires a masters in a behavioral health related field or Nursing degree. - Requires a minimum of two (2) years behavioral health clinical experience. - Behavioral health experience, preferably in a managed care setting, strongly preferred. - Active Unrestricted NJ LCSW, LMFT, LPC, RN License or Applied Behavior Analysis Certification Required. - Applied Behavior Analyst Certification preferred. Requirements - Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes. - Prefers knowledge in the use of intranet and internet applications. - Prefers working knowledge of case/care management principles. - Prefers working knowledge of principles of utilization management. - Prefers basic knowledge of health care contracts and benefit eligibility requirements. - Prefers knowledge of hospital structures and payment systems. Skills and Abilities - Analytical - Compassion - Interpersonal & Client Relationship Skills - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational Skills Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $70,500 - $94,395

Role Description This position will support Government Programs (GP) goal of improving quality of healthcare for our customers by ongoing monitoring of compliance with accreditation standards and regulatory requirements. This position will assist the Quality Management team in developing best practices for the coordination, facilitation, and oversight of all State and Federal accreditation activities. What You'll Do - Manages ongoing accreditation activity for all Government Programs lines of business to maintain the highest level of accreditation, including monitoring of standards, conducting gap analysis, and developing action plans to address identified deficiencies. - Ensures that all updates to accreditation standards, changes to State contracts and changes to CMS regulations, which affect accreditation are communicated to relevant departments, develops action plans to address the changes, and monitors compliance. - Creates and manages multiple accreditation project plans with tasks coordinated across departments at all levels of the organization. - Assembles accreditation project teams and assigns individual task responsibilities. - Ensures a continuous state of readiness for ongoing accreditation surveys and annual assessments. - Monitors delegates compliance with accreditation standards in collaboration with the Delegation and Vendor Oversight Department. - Educate and support operational area representatives in regard to accreditation requirements. - Interface with key staff and consultant(s) involved in accreditation survey/audit preparations and on-site survey/audit processes. - Maintain electronic accreditation libraries, ensuring all documentation is accurate and current. - Plans, coordinates and facilities training for internal and external stakeholders on aspects of accreditation Responsible for coordination of workflows and assignments for external reviews. - Participate in internal and external meetings as needed. Qualifications - Requires Bachelor's degree from an accredited college or university, preferably in Healthcare Management, or related field. - Requires a minimum of 3 years of experience in accreditation or regulatory field (i.e NCQA, URAC, etc.). - In lieu of degree, applicant must have a combination of an additional 5 years of equivalent and relevant work experience in managed care, preferably Medicaid. 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); Should be knowledgeable in the use of intranet and internet applications, including SharePoint and solid experience with Adobe. - Requires knowledge of NCQA standards. - Requires knowledge of state and federal regulations. - Requires knowledge of managed care principles. - Requires knowledge of project management. Skills and Abilities - Organizational and presentation skills. - Communication skills, oral and written. - Ability to prioritize and to multi-task in a fast-paced work environment. - Advanced planning and project management. - Detail-orientation. - Ability to plan and facilitate meetings. - Ability to effectively lead team members in diversified tasks. - Priority setting and time management. Salary Range $70,500 - $94,395 Benefits - Comprehensive health benefits (Medical/Dental/Vision). - Retirement Plans. - Generous PTO. - Incentive Plans. - Wellness Programs. - Paid Volunteer Time Off. - Tuition Reimbursement. Disclaimer Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Role Description This Medical Director role is responsible for designing, developing, and delivering provider education and performance management initiatives to support the Quadruple Aim: improve the patient and provider experience, improve population health, and improve affordability. The Medical Director will cultivate relationships with internal and external stakeholders and key providers to ensure the delivery of customized analytic and evidence-based performance management solutions that support quality outcomes and value-based care goals. The position will refine and devise strategy for provider and partner engagement to increase collaboration, improve care management, and encourage care delivery innovation. The Medical Director will lead a team of clinical transformation and quality improvement specialists. Responsibilities - Design curriculum for provider education including but not limited to value-based clinical workflows, utilization reduction strategies, quality, member experience, health equity and disparities, and appropriate risk adjustment/coding. - Develop provider education materials and approaches for providers at varying levels of readiness to transform: - Collaborate with internal and external SMEs (e.g. other medical Directors, quality and risk adjustment teams, and others) to receive relevant materials, insights, and strategies to be incorporated. - Partner with SIG and their many work-streams to ensure learnings and strategy are incorporated. - Research and incorporate global, national, and state-based leading evidence-based practices. - Use output of Voice of Provider surveys and Population health surveys to inform this work. - Create provider transformation evaluation process for benchmark and interval evaluation. - Identify and refine key KPIs, in collaboration with enterprise partners, to incorporate into partner-facing initiatives that will drive change in our VBP and FFS partner portfolio. - Research forward-thinking transformation practice models and programs for incorporation into partner playbooks to improve performance. - Partner with network facilities and providers to develop and implement initiatives that drive quality, manage cost, and improve performance. - Establish multidisciplinary teams for partner transformation engagement, for example, with transformation coach interactions, clinical collaboration calls, special KPI projects, etc. - Serve as physician SME for projects related to transformation and Health Care Value across the enterprise, such as Clinical Performance Measurement & Predictive Analytics, Strategic Initiatives Group, Medical Economics and Risk Adjustment, etc. - Design, update, implement, and review biannual value-based partner population health surveys. - Train value-based team on the interpretation of clinical insights reports and the message delivery to partners. - Research, design, update, and implement value-based quality program for each program year. Qualifications - Requires an Medical Doctor (MD) or Doctor of Osteopathy (DO) degree. - Requires a minimum of 10 years clinical experience in patient-centric/value-based setting, NCQA certification preferred. - Requires a minimum of 5 years of medical management experience in a managed care setting. - Requires physician leadership experience in integrated delivery systems with financial accountability. - Requires experience with management of physicians and non-physicians. - Current unrestricted Medical Doctor (MD) or Doctor of Osteopathy (DO) license from the state of New Jersey. Knowledge - Principles of population health and value-based care. - Principles of Utilization Management, URAC, NCQA UM Standards, and peer review. - State and federal regulations i.e. DOBI, DMAHS, CMS. - Principles and concepts of managed care and various models of health care delivery systems. - Principles and concepts of managed care operations, policies, and reimbursement. - Business of medical practice management. - Broad clinical knowledge and understanding of current health care issues. Skills and Abilities - Clinical: Strong clinical acumen to support understanding broad physical health issues, behavioral health issues, and social determinants of health. - Medical literature analysis. - Interpretation and application of medical policy to provide guidance to others. - Communication: Excellent verbal, written, and presentation skills. - Expertise in the delivery of highly technical information to a general audience. - Technology: Personal computer, applicable software, virtual communication platforms. - Business: Balance clinical issues with business imperatives and directives in the context of social responsibility. - Evaluate data from various sources to identify trends and issues. - Demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. - Manage multiple priorities, deliver timely and accurate work products with a customer service focus. - Ability to exercise sound judgment with strong problem-solving skills. - Manage physicians and employee staff. - Relationships: Build alliances with provider community and have insight into the mindset of practicing physicians in NJ. - Foster internal cross-organizational collaborations to support project design and delivery. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $214,100 - $297,885 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Role Description This position is responsible for initial claim pending resolution and claim adjustments. In addition, this position is responsible for the initial examining, coding, and input of claims and referrals into the various processing systems. - Resolve edits on claims (pending resolution) and may require claim adjustments. - Data entry of primary and secondary claims, as well as referrals into various processing systems. - Return claims with unidentifiable information back to healthcare professional/subscriber with letter requesting additional information. - Perform general clerical duties to ensure accurate disposition of claims/referrals that cannot be entered into the various processing systems. - Perform other related duties as required by Management. Qualifications - High School Diploma or equivalent required. - One (1) year of clerical business experience required. - Medical Terminology/Billing/Coding experience preferred. - Experience in a Production and Quality driven work environment preferred. Requirements - Must be proficient with the use of personal computers and supporting software in a Windows based environment, including MS Office products. - Should be knowledgeable in the use of intranet and internet applications; including ability to navigate. - Strong typing, data entry and keyboarding necessary. - Must be proficient using a calculator for simple math calculations. - Must be detail oriented with good organizational and data processing skills. - Proven ability to follow detailed instructions is essential. - Must demonstrate ability to learn quickly and apply learning to new situations. - Must exhibit flexibility to change as appropriate. Benefits - Comprehensive health benefits (Medical/Dental/Vision). - Retirement Plans. - Generous PTO. - Incentive Plans. - Wellness Programs. - Paid Volunteer Time Off. - Tuition Reimbursement. Company Description Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

Role Description This position is responsible for helping to identify, secure, and maintain community-based housing for MLTSS/SNP/Medicaid Members and for developing, articulating, and implementing a broader housing strategy within the Contractor to expand housing availability/options. The Housing Specialist(s) shall act as the Contractors central housing expert(s)/resource(s), providing education and assistance to all Contractors relevant staff (care managers and others) regarding supportive housing services and related issues for MLTSS Members. What You'll Do - Develop a housing strategy for Horizon membership (specifically MLTSS/SNP/Medicaid). - Identify and manage resources for housing options. - Provide education to all relevant staff, Care Management, Member Advocates and Utilization Management on housing options and resources. - Assist with locating and placing members in appropriate housing, facilitating transitions to community settings. - Complete reports to meet the state requirements; including but not limited to progress towards goals, quality monitoring. - Act as a liaison with DMAHS staff or its designee to receive training and capacity building assistance. - Work closely with relevant public and private housing resources and stakeholders, including but not limited to: - HUD subsidized housing - Department of Community Affairs (DCA) - New Jersey Housing and Mortgage Finance Agency (NJ HMFA) housing program voucher programs - Public housing authorities - Realtors - Online housing locator resources Qualifications - High School Diploma/GED required. - Three (3) years full-time experience in assisting vulnerable populations (e.g. homeless, elderly, people with disabilities, etc.) to secure accessible, affordable housing. - Two (2) years work experience for a public agency or related work in a social service or community service field. Requirements - Familiarity with relevant public and private housing resources and stakeholders, including but not limited to: - HUD subsidized housing - Department of Community Affairs (DCA) - New Jersey Housing and Mortgage Finance Agency (NJ HMFA) housing program voucher programs - Public housing authorities - Realtors - Online housing locator resources - Knowledge of Medicare/Medicaid. - Knowledge of Managed Long Term Services and Supports (MLTSS). - Strong interpersonal and advocating skills. - Strong verbal and written communication skills. - Good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word). - Good problem solving, investigation, mediation, and conflict resolution skills. - Good Reporting and Oral Presentation skills. - Strong organizational skills and ability to work with limited daily supervision. - Ability to use sound judgment and a professional approach. - Strong background in processing prior authorizations and proven expertise in navigating various systems, including familiarity with care management systems and state-managed entities such as the Homeless Management Information System (HMIS) and the Medicaid Eligibility Verification System. Travel - May require travel within New Jersey. - Requires a car with valid New Jersey State License and Insurance. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $70,500 - $94,395 Disclaimer Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Equal Opportunity Statement Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. About the Role Under general supervision, responsible for producing reports from various sources to provide the department /division with actionable information or business intelligence. This is an intermediate level position performing basic assignments, and may require guidance. What You'll Do - Evaluate, write, and present utilization and cost containment reports. - Determine or agree upon deliverables with customer, as well as determining the resources necessary to meet those deliverables. - May need to be a liaison with IT /vendor and customer. - May perform appropriate analysis on data: forecasting, modeling, regression. - Mine data from appropriate system and perform appropriate analysis on data. - May present data and provide feedback to client and customer; making necessary recommendations where appropriate. - Develop relationships with subject matter experts (SME). - Seek and adopt best practices in data reporting. - Perform other relevant tasks as assigned by Management. What You Bring Education/Experience: - High School Diploma/GED required. - Minimum 4 years experience in health insurance. - 2 years data reporting experience preferred. Knowledge: - Exposure to SAS and SQL systems preferred. - Strong PC skills - Prefer intermediate database management skills. - Understanding interdependencies among data Skills and Abilities: - Organizational, Multitasking, Analytical Thinking and strong Interpersonal Skills Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $63,000 - $84,420 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. About the Role This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators What You'll Do - Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients. - Prepare, document and route cases in appropriate system for clinical review. Initiates call backs and correspondence to members and providers to coordinate and clarify benefits. - Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion. - Reviewing professional medical/claim policy related issues or claims in pending status. - Acts as liaison with providers, members and Care Managers. - Perform other relevant tasks as assigned by Management. Utilization Management: - Upon collection of clinical and non-clinical information MCC can authorize services based upon scripts or algorithms used for pre-review screening. - Non Clinical staff members are not responsible for conducting any UM review activities that require interpretation of clinical information. - Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff. Case Management: - Assists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal. - Makes outbound calls to in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey*.) - Educates members regarding preventive health activities and services. - Assists member to make appointments with their PCP, specialists, and/or transportation, etc. Handle PCP, demographic changes and/or new ID cards as requested by members. - Triage and distribute referrals from Member Services and incoming faxes from providers. - Reviews medical, dental and vision claims and address gaps in member's preventative care. Addendum for Letter’s Team Only: - Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards. - Perform initial screening of determination letters, ensuring clarity and compliance before distribution. - Make sound, timely decisions under the direction and supervision of a designated Supervisor. What You Bring Education/Experience: - High School Diploma/GED required. - Prefer 1-2 years customer service or medical support related position. Knowledge and Skills: - Requires knowledge of medical terminology, Preferred – Medicaid CM. - Requires Good Oral and Written Communication skills. - Requires ability to make sound decisions under the direction of Supervisor. - Prefer knowledge of contracts, enrollment, billing & claims coding/processing. - Prefer knowledge Managed Care principles. - Prefer the ability to analyze and resolve problems with minimal supervision. - Prefer the ability to use a personal computer and applicable software and systems. - Team Player, Strong Analytical, Interpersonal Skills. Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $44,600 - $59,745 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Role Description Provides support and consultation to the Health and Network Solutions (HNS) through analyzing key business issues related to cost, utilization and revenue for all products at Horizon BCBS. Design and develop reports to monitor and identify the root causes of Medical and Provider cost trends. Collaborate with cross functional teams to identify opportunities to help bend the medical cost curve. Identify opportunities to reduce manual processes and interventions and develop systemic solutions to drive efficiency. What You'll Do - Develops analytics to evaluate the performance of medical and provider cost activities across Health and Network Solutions (HNS) and consults with business leaders on observations and recommendations. - Identifies favorable and unfavorable trends, develops recommendations to improve trends, communicates recommendations to management, and analyzes the financial performance of all Horizon BCBS products, including Commercial, Medicare, and Medicaid. - In partnership with the director, directs the development and implementation of advanced analytic tools and techniques to identify cost drivers and ways to improve medical and provider cost performance. - Expands the evaluation of provider performance, benchmarking providers across multiple cost of care categories, and provides input and recommendations to contracting teams to guide contract negotiations, network strategy, and overall enterprise understanding of provider performance. - Partners with the director and collaborates with finance and actuarial teams to connect medical and provider cost activities to the enterprise processes including forecasting, budgeting, and pricing. - Supports the director in maintaining effective internal controls over the processes and transactions under areas of responsibility, including the completeness and accuracy of financial information and transactions, compliance with applicable laws and regulations, and the effectiveness and efficiency of operations. - Identifies opportunities to reduce manual processes and interventions and develops systemic solutions to drive efficiency. - Manages, develops, and trains staff; develops and monitors goals; conducts annual performance reviews, and administers staff salaries. Qualifications - High School Diploma/GED required. - Bachelor degree in math, statistics, actuarial, finance, accounting, economics, business administration or a related field preferred or relevant experience in lieu of degree. - Minimum of 5 years of experience in developing complex financial models to support business decisions. - Minimum of 3 years experience with Advanced SAS and/or SQL, including creating queries, pulling large data sets, and performing data manipulations/analysis. - Minimum of 5 years of experience in health care/managed care with direct responsibility within a Financial Planning & Analysis (FP&A) and/or Medical Cost Management & Analysis discipline. - Demonstrated experience leading big projects with cross-functional departments at various levels. Requirements - Knowledge of Government Program, Commercial, Medicare market sectors and products. - Ability to communicate complex concepts to a non-technical audience in a digestible manner using data visualization. - Knowledge of healthcare financial terms such as cost, utilization, Per Member Per Month (PMPM), and revenue. - Advanced knowledge with Excel, including working with large data sets, creating standardized reports, utilizing vLookups and advanced functions/formulas, and interpreting pivot tables. - Demonstrated aptitude for analytical thinking and the ability to report findings accurately. - Progressive understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, product pricing, network and provider contracting, and utilization management. - Strong problem-solving and analytical skills; experience with relational databases and techniques. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $109,600 - $149,625. This compensation range is specific to the job level and takes into account various factors, including education, experience, licensure, certifications, geographic location, and internal equity.

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. About the Role The position is responsible for leading the managed long term support and services program clinical care team in a hands-on manner to provide exceptional service to the customer and contain medial claims cost. This is accomplished through active involvement and leading of the day-to-day operations of a clinical care team and ensuring staff is consistent with corporate policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, and non-clinical staff. What You'll Do - Supervises, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions. - Continuously evaluates workflow issues and seek to improve processes that impact the managed long term support and services department. - Coordinates data collection, reviews compliance reports and identifies opportunities for service improvements. - Recommends, develops and implements department polices and procedures and interfaces with other areas to insure consistent applications. - Liaison between Medical Directors and staff. - Develops and monitors goals for staff and provides ongoing feedback and coaching. - Conducts performance reviews on an annual basis and administers salaries for the staff. - Directs the employment activities of the office that include staffing, development, and training. - Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures. - Performs the operational duties of a specific clinical care team. - Ensures an atmosphere within the team, which fosters open communication, teamwork, ownership, and empowerment to make decision. - Develops key performance indicators to evaluate level of service for internal and external customers. - Acts as technical expert and reference point for difficult and complex matters. - Facilitates the creation of service and processing innovations within the team. Shares innovations with other teams and market divisions. - Assists in preparing and monitoring the budget to ensure administrative cost objectives are met. Identifies and implements cost saving/revenue generating opportunities. - Interprets and executes policies for the team. - Participates in special projects initiated by the Plan. - Assists Manager in coordinating regulatory, quality and accreditation activities. - Represents the Plan with external customers, providers and agencies. - Represents the department on internal committees What You Bring Education/Experience: - High School Diploma/GED required - Bachelor degree preferred or relevant experience in lieu of degree - Requires two (2) - four (4) years acute healthcare experience. - Prefers one (1) year experience as a supervisor. - Prefers one (1)- three (3) years experience in the health insurance industry. - Certification as a case manager preferred. - Professional certification in a clinical specialty and at least three years experience as a case manager preferred. Additional licensing, certifications, registrations: - Active Unrestricted NJ RN/SW License Preferred. Candidates with a restricted license will not be considered. Knowledge: - Requires knowledge of Utilization Management (UM) and managed care principles as they relate to the CCM process and Elderly Frail /Managed Medicaid Population based CM - Requires knowledge of the Case Management/Disease Management Standards of Practice. - Requires knowledge of health care systems and medical documentation. - Requires understanding of claims processing, contracting and enrollment. - Requires knowledge of State Mandates and Regulations, including HIPAA and HCQA. - Requires knowledge of regulatory bodies and their processes including HCFA and DOBI. - Requires knowledge of NCQA and URAC accreditation criteria related specifically to UM/DM and Case Management. - Requires knowledge of community health resources. Skills and Abilities: - Requires the ability to express thought clearly and concisely both orally and written. - Requires the ability to obtain the skills possessed by the team members and system technical competence. - Require the ability to effectively lead team members in diversified tasks. - Requires excellent organizational skills. - Requires excellent presentation skills. - Requires the ability to think analytically and to report findings in an accurate manner. - Requires knowledge of computers and their related software packages. Travel: - Minimum local travel required Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $87,300 - $119,070 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.