Horizon Blue Cross Blue Shield of New Jersey

Role Description This position is responsible for providing oversight for the State and Federal Out of Network (OON) Mandate program(s). The position supports the development and implementation of standards, systems, policies, and procedures in alignment with organizational strategic initiatives, ensuring compliance with all State, Federal and Association mandates pertaining to out of network payment rules (i.e. Out of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (OON Mandate). What You'll Do - Supervises, analyzes and coordinates the work of the business team to ensure that quality and productivity goals are met. - Provides help, guidance, training, technical training and instructions to staff so that team members can improve their performance and broaden their skill sets. When necessary, performs the operational duties of the business team members. - Ensures an atmosphere within the business team which fosters open communication, teamwork, participation, ownership, and empowerment to make decisions. - Evaluates the performance of the business team as a whole and of the individual members of the team. - Ensures that the customer is satisfied with the level of service provided. - 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. - Monitors and reports on key performance indicators to team members and to upper management. - Assists in preparing and monitoring the budget to ensure administrative cost objectives are met. Identifies and implements cost saving/revenue generating opportunities. - Interfaces with other teams and plan areas to assure consistent application of policies and procedures and to facilitate inter-unit/department projects. - Interprets and executes and modifies policies for the business team. - Participates in special projects initiated by the Plan. - Represents the Plan with external customers, providers and external agencies. - Develop/Update enterprise-wide training material related to OON Mandate Surprise Billing handling. - Represent Surprise billing functions on divisional and enterprise work groups. May be responsible to lead some such groups. Supervisory Accountability Statement - Maintains a motivated and productive staff by providing sound leadership and direction; models appropriate behavior; renders timely decisions; provides coaching, feedback and recognition; conducts appropriate and timely performance appraisals; selects the best qualified candidates to fill job vacancies; administers company policies fairly; provides for development activities and opportunities to assure the application and assessment of skills learned. What You Bring Education/Experience: - High School Diploma/GED required. - Bachelor degree preferred or relevant experience in lieu of degree. - Requires a minimum of three to five years experience in a professional business environment. - Prefer three to five years experience as a supervisor. - Prefer three to five years experience in the health insurance industry. Knowledge: - Requires three to five years experience medical claims processing. - Require extensive knowledge of computers and software relative to the business and extensive knowledge of functional tasks performed within the team. - Require general knowledge of tasks performed by areas that support the business team. - Require knowledge of medical and/or health insurance industry. Skills and Abilities: - Require the ability to express thought clearly and concisely both orally and in writing. - Require the ability to obtain the skills possessed by the team members and to demonstrate technical competence on systems used. - 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. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $87,300 - $119,070

Role Description This role will facilitate and lead negotiations with Horizon's network of provider partners of over 32,000 professionals, 1,500 ancillary providers, and 76 hospitals in our New Jersey, Pennsylvania, and New York markets representing billions in spend. Negotiations will include but are not limited to Hospitals, Physicians, and Ancillary providers, including value-based programs for all of Horizon's medical lines of business including Commercial, Medicare, Medicaid, DSNP, MLTSS, and Casualty services. The role will collaborate with the Medical Economics, Payment Model Evolution Team, and Provider Experience teams in preparation for contract rate proposals that adhere to Horizon’s unit price trend budget, standard payment methodologies, standard contract language, ensure compliance with all regulatory, accreditation, and enterprise requirements while advancing Horizon’s strategic and business objectives. The role will work directly with the Manager on fee-for-service and value-based payment contracting initiatives for all Horizon lines of business, collaborating with the Payment Model Evolution Team when appropriate to introduce updated payment models. The role will facilitate the execution of network contracting strategy and maintenance of contracting policies. Qualifications - High School Diploma/GED required. - Bachelor's degree in business, finance, accounting, health administration preferred or relevant experience in lieu of degree. - Preferred Master’s degree in health or business. - Requires a minimum of 5 years of business experience in hospital finance and/or managed care network development. - Requires a minimum of 5 years demonstrated experience in two or more with in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Medicare DRG and APC’s, Medicaid pricing, capitation, full risk, shared savings, and incentive arrangements. - Requires a minimum of 5 years provider experience in Commercial, Medicare, Medicaid, and Value Based Programs. - Requires a minimum of 5 years’ experience in hospital finance and/or managed care network development. - Requires a minimum of 5 years’ experience in health care cost data analysis and technical document writing. Requirements - Understands the Enterprise Strategic and Financial Plan. - Understands the credentialing and recredentialing process, provider directory maintenance, and regulatory standards. - Understands Value Based Programs including the financial, quality, and operational aspects. - 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. - Requires knowledge of Principles of Health Care contracting. - Requires knowledge of health care industry or health insurance industry. - Requires knowledge of the hospital and physician communities in the state of New Jersey. - Requires knowledge of laws and regulations regulating insurance, HMO hospital and physician practice. - Requires knowledge of quality measurement approaches applied in measuring insurance, HMO, hospital, and physician practice. 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 receiving verbal and written requests for prior authorization from pharmacists, physicians and/or members. They are accountable for supporting and assisting in the coordination of Pharmacy Services benefits, including: - Claim utilization analysis - Prescription plan design - Ad-hoc reporting - Correspondence and special projects This position must ensure performance is in compliance with organizational or departmental goals and in compliance with regulatory agencies. They must process prior authorization requests received via fax or prior authorization help line, by evaluating the medical necessity/appropriateness for specific drugs and based on clinical criteria. What You'll Do - Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues. - Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design. - Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination. - Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied. - Process complaints, appeals, grievances, executive inquiries and compliance related issues. - Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary. - Provide recommendations to increase efficiency, accuracy and productivity in the department. - Process ad hoc request for information or reports from stakeholders. - Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows. - Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program. - Provide support to various clinical programs within the pharmacy department. Qualifications - High School Diploma/GED required - Minimum of two (2) years experience as a Pharmacy technician - Minimum of two (2) years experience in third party prescription program claim adjudication preferred - Prior customer service/service quality initiative experience required - National Pharmacy Technician Certification (PTCB or ExCPT) required - In lieu of the Pharmacy Tech Certification, a minimum of 5 years’ experience as a retail pharmacy technician or relevant pharmacy experience in managed care or a PBM (Pharmacy Benefit Management) organization required Requirements - Knowledge of popular brand and generic drug names - Knowledge of third party prescription program claim adjudication - Working knowledge of managed care principles - Knowledge of common medical terminology - Understanding of National Drug Code (NDC) - Knowledge of State of New Jersey Board of Pharmacy regulations and State Federal controlled substances regulation Skills and Abilities - Ability to utilize a personal computer and applicable software - Effective verbal and written communication skills - Ability to work well within a team - Ability to deliver highly technical information to less technical individuals - Demonstrated professional and ethical business practices, adherence to company standards, and commitment to personal and professional development - Proven time management skills - Ability to manage multiple priorities, deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required - Ability to work in a production focused environment - Ability to exercise sound judgment and strong problem solving skills - Ability to ask probing questions and obtain thorough and relevant information Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $44,600 - $59,745

Role Description This position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized. - Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members' needs and aligned with benefit structure. - Evaluates the necessity, appropriateness, and efficiency of service provided. - Develops, coordinates, and assists in implementation of services to meet the needs of the members. - 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. - Refers members to MLTSS when appropriate. - Educates members on the availability of SNP if appropriate. - 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. - Performs duties as assigned by management. Qualifications - High School Diploma/GED required - Bachelor degree preferred or relevant experience in lieu of degree - A minimum of two (2) years clinical experience is preferred - Active Unrestricted NJ RN License Required Requirements - 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. - Working knowledge of case/care management principles. - 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. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Travel (If Applicable) - Requires a car with valid New Jersey State License and Insurance Salary Range $70,500 - $94,395 Addendum - Completes NJ Choice Home Care Assessments for new referrals to MLTSS. - Assists with MLTSS Case Management when necessary, to cover for FMLA or to maintain MLTSS Caseloads below contractual obligations. - Provide support when needed to MLTSS Care Management Staff, including but not limited to Annual Assessment, 90 day and/or Post Hospital visits.

Role Description This role supports actuarial and data analytics for risk-adjusted business across ACA, Medicare Advantage, and Medicaid. Responsibilities include analyzing risk scores, financial impacts, and performance metrics, as well as developing insights to guide risk adjustment strategy, reporting, and pricing/forecasting efforts. The position requires strong analytical skills and the ability to translate data into actionable business recommendations. What You'll Do - Perform or support actuarial analytics on risk adjustable lines of business, including ACA, Medicare Advantage, and Medicaid. - Perform or support CMS-HCC and HHS-HCC risk score projections, including RATP, MA MYRA/FYRA accruals, and RADV financial impacts. - Perform or support data analytics and reporting to inform risk adjustment operations, strategy, submissions, and vendor performance. - Perform or support financial metrics pertaining to risk adjustment performance, including but not limited to intervention ROI. - Collect and analyze data to use for financial and utilization reporting and monitoring. - Support pricing and forecast efforts, including ACA pricing and MA Bid submissions. Qualifications - Bachelors degree is required, preferably within Mathematics, Statistics, Actuarial Sciences or a related field from an accredited college or university. - Requires 2+ years of actuarial and/or statistics experience or attainment of Associate level in the Society of Actuaries (ASA). - ASA candidate a plus. Requirements - Requires working knowledge of Excel. - Prefers experience with SAS or other programming language. - Prefers knowledge of data analysis and Actuarial principles. Skills and Abilities - Requires good oral and written communication skills. - Requires strong analytical thinking. - Requires strong mathematical skill and statistical analysis abilities. - Requires good judgment and problem solving skills. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $79,100 - $105,945

Role Description This position is accountable for the conservation of existing accounts and selling additional product lines where appropriate and profitable for the Public markets. - Manages contract renewals and ensures services are provided that will maximize the potential for account retention and initial member enrollment. - Plans and negotiates terms and conditions of contracts with existing accounts. - Sells additional lines of business to existing clients. - Compares and evaluates various products to make appropriate recommendations based on client needs assessment. - Modifies existing contracts that require term changes that may be outside of predetermined guidelines or standards. - Develops and conducts workshops for clients/groups relative to enrollment, claim procedures, and health industry regulations. - Weighs factors and outcomes to make binding financial, operational, and service-related decisions. - Ensures that all clients and stakeholders are promptly informed of relevant legislative and regulatory issues and their associated impact. Additional duties for the Labor market: - Sells new business to potential accounts, working towards sales goals while ensuring the sale of prudent and profitable business. - Develops prospective accounts and clients. - Informs and educates prospects on Horizon products and services. - Performs other duties as assigned by management. Qualifications - Minimum high school diploma or GED. - Bachelor's degree preferred. - Requires a minimum of seven (7) years of professional sales or contract negotiation experience, preferably in the health insurance industry, with a documented track record of success. - Requires a New Jersey State Health/Life License. Requirements - Must be proficient and possess advanced skills in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes. - Should be knowledgeable in the use of intranet and internet applications. - Requires knowledge of Group Health products lines including Managed Care. - Requires knowledge of rating and policy renewal practices. - Prefers knowledge of Horizon BCBSNJ products, underwriting policies, enrollment, billing, and claims processing procedures. Skills and Abilities - Negotiation - Verbal and written communication - Public speaking and presentation - Interpersonal - Relationship-building Travel (If Applicable) - Travel throughout New Jersey is required. Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Salary Range $92,100 - $120,855. This position is eligible for sales incentive compensation in addition to base pay.

Role Description This position provides Rating & Underwriting services and support to the Sales team and is responsible for the production of rates for the 51+ markets. - Develops and issues renewal rates for group size 51+. - Manages book of business independently up to authority limits, providing recommendations and analysis to Sales. - Analyzes both Account specific metrics and marketplace data to determine appropriate rate levels. - Approves Group Enrollment Information (GEI) and Benefit Information Forms (BIFs) where applicable. - Researches rate and benefit inconsistencies and issues corrections and/or recommendations. - Assembles data and produces ERISA 5500 reports and issues to Sales, where applicable. - Performs other duties as assigned by management. Qualifications - High School Diploma/GED required. - Minimum one (1) year business experience, preferably in an insurance environment. Requirements - Prefer knowledge of Horizon BCBSNJ products. - Prefer knowledge of underwriting principles, benefit offerings, alternate financial mechanisms and rating methodology. - 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 Lotus Notes. - Should be knowledgeable in the use of intranet and internet applications. - Excellent Math abilities to be determined via interview and/or testing. - Analytical & Problem Solving Skills. - Attention to Detail. - Time Management. - Customer Focus. - Teamwork. - Self-Motivated. 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. Serves as mentor/trainer to new BH Clinicians and other staff as needed during the performance of their daily job duties. What You'll Do - 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, for both acute and chronic health care needs when applicable. - Develops, coordinates and assists in implementation of plan for members and of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness. - Demonstrates a high level of knowledge and understanding of the application of Milliman Care Guidelines (MCG) and American Association of Addiction Medicine (ASAM) criteria to medical necessity criteria. - 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, including transitional care where applicable. - 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. - Serves as mentor/trainer to new BH Clinicians and other staff on an ongoing basis. - Serves as an escalation point for cases and issues that require additional attention. - Coordinates the implementation of clinical process improvement with the support of the team supervisor. - Works independently on special projects in conjunction with the supervisor that support the needs of the business. - Provides feedback and collaborates with department supervisor in evaluating areas of needed improvement within the team. - Completes other assigned functions as requested by management. - Works independently on complex cases. - Recommends workflow and process improvements. - Executes UAT test cases thoroughly from end to end. - Required to work one holiday shift per year. Education/Experience - High School Diploma/GED required. - Bachelor degree in a behavioral health related field or Nursing degree preferred or relevant experience in lieu of degree. - Prefers a masters in a behavioral health related field or Nursing degree. - Requires a minimum of 2 years behavioral health clinical experience. - Requires 1 year behavioral health experience in a managed care setting or health insurance industry. Additional Licensing, Certifications, Registrations - Active Unrestricted NJ LCSW, LMFT, LPC, LBA or RN License Required. - CCM Certification preferred (for BH Clinical Advocate roles). 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 Lotus Notes. - 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 - Bi-lingual proficiency preferred (for BH Clinical Advocate roles). Travel - For field based positions, travel required 100%. - Travel to office locations as required (for BH Clinical Advocate roles). Salary Range $79,100 - $105,945 Benefits - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement

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. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed. What You'll Do The Transplant Case Manager acts as an individual’s primary advocate and care coordinator throughout the entire transplant journey, from initial evaluation and education to post-transplant recovery and long-term care. The Transplant Case Manager navigates complex medical, social, and financial barriers by coordinating with multiple providers and agencies, ensuring appropriate care access, and providing crucial support to individuals and their families during a challenging and emotional process. - 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. - Serves as mentor/trainer to new RN's 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. Addendum for Horizon Clinical Advocate Roles - Outreaches to members identified by Horizon as needing Clinical Advocate services. - Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment. - Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques. - Becomes knowledgeable in ASO client employer-sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language. - Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. - Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional. What You Bring Education/Experience: - 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 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. Addendum for Horizon Clinical Advocate roles: - CCM certification preferred. 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. Addendum for Horizon Clinical Advocate roles: - Requires ability to be an empathetic critical thinker. - Requires excellent communication and organizational skills and a high tolerance for ambiguity. - Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization. - Experience in active listening and motivational interviewing strongly preferred. - Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills. - Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion. Skills and Abilities - Adaptability/Flexibility - Analytical - Compassion - Interpersonal & Client Relationship Skills - Information/Knowledge Sharing - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational 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 $79,100 - $105,945 - 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 The Risk Adjustment Data Analyst III is a seasoned analyst responsible for playing an active role in submission, monitoring and contributing to the end to end Risk Adjustment Data Submission and Validation within key regulator guidelines for acceptable data submission. The analyst will also be responsible for oversight and participation in the timely completion of projects, including timeline development & maintenance as it pertains to encounter and risk adjustment data. What You'll Do - Collaborate with internal and external stakeholders involved in Risk Adjustment data submission, as well as all other mandatory aspects of Risk Adjustment. - Perform analysis and reporting activities related to risk score calculation, encounter data submission, chart review programs and audits, and related performance metrics per regulatory and health plan guidelines. - Research and document encounter errors in established systems and databases with appropriate statistical trend analysis, perform root cause analysis of encounters processing and submission issues and develop recommendations based on data and industry standards. - Contribute to the creation of technical documents and high level solution designs. - Participate in the development, testing and implementation of system specifications. - Interact with RA leadership to create predictive models using information obtained from data mining or analysis. - Assist in onboarding and coaching of junior analysts. Actively participate in the peer review process by reviewing, providing insight, and verifying work of junior analysts. - Conduct gap analysis, data collection and validation related to Risk Adjustment activities. - Contribute to program improvement by designing and implementing business process and system changes, collaborate to resolve encounter data and process issues and manage policy and procedure documentation. - Use data from internal and external sources, analyze complex encounter inbound/outbound process issues to provide insight to decision-makers. - Support and participate in internal and external audits as needed. - Produce recurring and ad-hoc reports for business stakeholders for risk adjustment optimization. - Remain informed and updated on industry changes e.g. CMS regulations and changes (EDPS, Risk Adjustment Payment Model Changes). Qualifications - Bachelor’s degree preferred from an accredited college or university preferably in Computer Science, Data Science or other strong analytical field. - Master’s degree a plus. - Requires a minimum of five (5) years of experience with programming or analytics, preferably in health care, insurance or related field; clinical and medical claims data and disease diagnostic coding practice a plus. - Experience with manipulating large amounts of clinical and medical claims data while working in health care industry, insurance or related field. - Requires experience using programming and statistical software (e.g., SAS), use of various databases and other data sources, and performing analytics. Requirements - SAS, Oracle, or SQL certification a plus. - Advanced knowledge in Excel (including pivot tables) and Access required. - Advanced knowledge of SAS, Oracle or SQL required. - Knowledge of R and Python is a plus. - Knowledge of risk adjustment programs for Medicare/Medicaid, or risk mitigation programs under ACA, is a plus. Skills and Abilities - Strong analytical, research and problem-solving skills; experience with relational database and techniques. - Strong attention to detail. - Written and oral communication skills. - Proficiency in Microsoft software applications. - Ability to perform and interpret a variety of data analyses. - Demonstrated ability to evaluate and interpret complex data. - Demonstrated ability to handle multiple tasks with competing priorities. Benefits - Comprehensive health benefits (Medical/Dental/Vision). - Retirement Plans. - Generous PTO. - Incentive Plans. - Wellness Programs. - Paid Volunteer Time Off. - Tuition Reimbursement.