NJM Insurance Group

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure • Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs • Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness • Coordinates with members, 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 • Monitors member'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 • 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 • Presents clinical cases during audits conducted by external review organizations • Performs other duties as assigned by management.

• Handle all Utilization Management medical appeal cases • Ensure timeliness guidelines are met and appeals handled in compliance with regulatory requirements • Provide mentoring and clinical liaison support to appeals staff • Assess patient's clinical need against established guidelines • Evaluate the necessity, appropriateness and efficiency of medical services • Perform review of medical records • Investigate and resolve complicated appeals • Prepare and present appeals to Appeals Committee • Document accurately and comprehensively • Interact and communicate with facilities, physicians and members/families • Evaluate care by problem solving and analyzing variances • Facilitate the external review process with the IURO and IRO • Provide 24/7 on call appeal support as scheduled

• Researches, investigates and coordinates resolution to member and/or provider complaints • Utilizes IMAC database to extract complaint information and tracking log • Ensures complaint resolutions meet State timing requirements to ensure compliance • Gathers data to compile monthly and quarterly statistical reports • Conducts extensive follow-up with internal areas • Writes complaint resolution letters to physicians and members • Reviews the complaint database report weekly and follow-up on outstanding issues • Completes and/or assist with monthly reporting requirements • Performs any other duties as assigned by management

• Conduct end-to-end process reviews across front-office, middle-office, and back-office operations to identify inefficiencies, bottlenecks, and improvement opportunities • Perform root cause analyses to determine underlying operational issues and identify sustainable solutions • Design future-state business processes aligned with enterprise service strategies, customer experience goals, and operational objectives • Develop process maps, workflows, business requirements, and supporting documentation to drive transformation initiatives • Evaluate and recommend opportunities to simplify, standardize, and optimize operational processes • Partner with EBTS, Operations, and business stakeholders to translate business needs into effective process and technology solutions • Support requirements gathering, solution design, and implementation planning • Ensure business processes and system capabilities are aligned to operational objectives and customer expectations • Collaborate with cross-functional teams to deliver enterprise transformation initiatives successfully • Lead and support operational readiness activities for new systems, processes, and business initiatives • Coordinate business implementation activities, including cutover planning, staffing readiness, workflow transitions, and go-live preparation • Support User Acceptance Testing (UAT), pilot programs, and post-implementation validation activities • Assess organizational readiness and identify risks that may impact successful implementation • Identify opportunities for automation, digitization, and workflow optimization • Monitor post-implementation performance and identify stabilization issues requiring corrective action

• Lead enterprise change management and adoption planning efforts for service transformation initiatives across Operations • Ensure organizational readiness, stakeholder alignment, effective communication, and sustainable adoption of business and technology changes • Develop and execute comprehensive change management strategies that minimize disruption, mitigate risk, and maximize business value • Conduct stakeholder assessments and impact analyses to identify change impacts and readiness needs • Coordinate technology releases and operational changes impacting business units • Identify operational risks associated with business and technology changes • Measure change adoption, stakeholder engagement, and implementation effectiveness

• Develop and enhance vulnerability scanning strategies to ensure comprehensive coverage • Conduct internal and external vulnerability assessments and validate scan results • Apply established vulnerability management standards to classify vulnerabilities • Categorize and prioritize assets according to criticality • Partner with EBTS teams to develop and execute vulnerability remediation plans • Track and report remediation activities • Analyze emerging cyber threats and assess potential impacts • Communicate current risk exposure and remediation efforts to senior leadership • Develop, maintain, and present vulnerability management metrics and executive reports • Create, update, and maintain policies, standards, procedures related to vulnerability management • Ensure security controls are operating effectively to satisfy audit and regulatory requirements • Assist in the development of a threat hunting program • Collaborate with internal teams to investigate, validate, and resolve vulnerability findings

• Supports Clinical Operations functions and acts as liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators • Performs review of service requests for completeness of information and collection of non-clinical data • Initiates call backs and correspondence to members and providers to coordinate and clarify benefits • Handles initial screening for pre-certification requests via calls or correspondence based on scripts and workflows • Assists members with finding providers, resolving problems and answering questions regarding services • Makes outbound calls to engage members in Case Management and to complete necessary health assessments • Educates members regarding preventive health activities and services • Review medical and administrative documentation for accuracy and compliance standards

• Assist in the development and maintenance of premium rates for the Individual and Small Group markets. • Support the preparation, validation, and submission of premium rate filings to state and federal regulatory agencies. • Analyze and evaluate proposed benefit design and cost-sharing changes to determine financial and actuarial impacts. • Conduct pricing analyses, actuarial studies, and financial modeling to support product and rate development initiatives. • Assess the impact of proposed state and federal legislative, regulatory, and healthcare reform changes on pricing and product strategy. • Perform Mental Health Parity compliance reviews and support related regulatory reporting requirements. • Conduct experience analyses and drill-down studies to identify emerging trends, utilization patterns, and key cost drivers. • Develop ad hoc actuarial models and analytics to support strategic decision-making and business initiatives. • Collaborate with Product, Finance, Underwriting, Regulatory, Compliance, and other business partners to evaluate assumptions and recommendations. • Review and analyze data from multiple sources to support actuarial projections and risk assessments. • Prepare reports, presentations, and recommendations for management, clearly communicating complex actuarial concepts and analytical findings.

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure. • Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider. • Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs. • Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness. • Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. • Monitors member'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.

• Assess member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure • Facilitate response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider • Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs • Develop, coordinate and assist in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness • Coordinate with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome • Coordinate 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 • Monitor member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness • Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided • Encourage member participation and compliance in the case/disease management program efforts • Document accurately and comprehensively based on the standards of practice and current organization policies • Interact and communicate with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care • Evaluate care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes • Serve as mentor/trainer to new RN's and other staff as needed • Present clinical cases during audits conducted by external review organizations • Perform other duties as assigned by management