NJM Insurance Group

• Supports the Health Services and Utilization Management functions • Acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators • Prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings • Mentors more junior staff by responding to questions and sharing expertise • Adheres to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows • 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 • Manages correspondence of toll-free UM Appeal hotline and UM Appeal fax server • Interacts with and supports Medical Directors • Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors • Prepares, documents and routes cases in appropriate system for clinical review • Responsible for the comprehensive explanation of previous denials, the scope of coverage, and applied criteria • Conducts and provides root cause analysis to avoid future appeal occurrences.

• Assess member’s clinical need against establish guidelines and/or standards for specialty population-based members. • Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan. • Partner with the member/family, physician, and all members of the healthcare team to ensure the member’s needs are met, internal and external to this organization. • Advocate for the member among various sites to coordinate resource utilization. • Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status. • Ensure care for mandated non-compliant members through the monitoring of utilization. • Document accurately and comprehensively based on the standards of practice and current organization policies. • Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes. • Monitor member’s care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness. • Consult with internal stakeholders on complex cases and escalate as appropriate to internal physician resources. • Complete other assigned functions as requested by management.

• Responsible for performing RN duties using established guidelines to ensure appropriate level of care. • Plans for the transition to the continuum of care. • Assesses patient's clinical need against established guidelines. • Coordinates and assists in implementation of plan for members. • Monitors patient's medical care activities and outcomes for appropriateness and effectiveness. • Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. • Serves as mentor/trainer to new RN's and other staff as needed. • Represents clinical teams within committee meetings.

• Conduct detailed root cause analysis on service or operational issues • Develop and maintain forecasting models and analytics dashboards using modern tools such as Excel, SQL, and BI platforms (Power BI/Tableau) • Integrate data across multiple systems and ensure data integrity for reporting and operational decision-making • Translate business needs into clear functional requirements and partner with IT to build, enhance, or troubleshoot system capabilities • Develop data-driven recommendations and implement process improvements that enhance efficiency, accuracy, and customer experience • Lead or contribute to project teams, facilitate working sessions, and deliver presentations to internal and external stakeholders • Own or support User Acceptance Testing (UAT), including test planning, execution, documentation, and validation of system enhancements or fixes • Prepare documentation for internal/external audits and support audit reviews by validating findings, addressing discrepancies, and recommending corrective actions • Provide mentorship and guidance to junior analysts, assist with onboarding new team members, and support workload distribution where needed

• Key member of account management team for selling new business, inclusive of ancillary products • Create and facilitate client presentations and meetings • Analyze data to recommend changes and cost saving designs incorporating medical management programs • Respond timely and proactively to account or broker telephone inquiries • Build strong internal and external relationships • Resolve complex service issues and answer product and benefits questions • Assist in processing paperwork relating to prospecting, enrollment, and/or termination of accounts • Maintain accuracy of account profile and group administration • Facilitate timely implementation of new groups and conversions • Analyze inter-departmental problems and recommend resolutions • Assist in the procurement of information to complete and verify sale documentation • Responsible for reporting requests and confirming data accuracy • Perform other duties as assigned by management

• Manages contract renewals and ensures services are provided that will maximize the potential for account retention and initial member enrollment • Majority of account management and sales are via phone call and emails. • Ensures proper installation of new accounts as well as changes to existing accounts. • 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. • Ensures that all accounts are promptly informed of relevant legislative and regulatory issues and their associated impact. • Performs other duties as assigned by management.

• Conducting data collection and analyses to support process improvement programs and projects • Leading a variety of initiatives, ranging in complexity and scope, within business divisions • Drafting and reviewing project deliverables and analyses such as value-stream mapping and statistical analyses • Supervising business process analysts in the project team environment • Developing business cases using ROI models in direct relationship to strategic corporate goals • Interacting with subject matter experts to develop solutions that improve process performance • Planning and participating in BPI organization building and activities to help promote the BPI brand

• Support all lines of business which includes Commercial and Government Programs. • Collaborate with value-based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable. • Supports sales teams as assigned by region. • Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable. • Consult with/support case management to determine best course for members, assist with PG and address issues. • Develops and maintains effective collaborative relationships with providers in assigned geographic areas. • This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers. • May provide input into provider credentialing, profiling and communication initiatives. • Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management. • Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix. • Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region. • Assists with assessment of network capabilities by region and collaborates with network management, contracting and value-based teams in addressing network gaps. • Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas. • Participates in Committee activities as assigned. • Assist with coverage across functional MD teams, as needed, including participation in calls for all areas. • Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team. • Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI).

• Support forecast development and financial projections, reserves and analytics for the Medicaid lines of business. • Assess the impact of proposed state and federal legislative changes. • Perform experience analysis for Medicaid products, including medical cost, utilization, and trend components. • Monitor emerging experience and identify drivers of variance from expected results. • Prepare actuarial exhibits, summaries, and documentation for internal leadership and external stakeholders. • Provide support for additional actuarial projects as requested. • Assist with Medicaid quarterly financial reporting, certifications, and responses to state inquiries. • Support analysis related to benefit changes, policy updates, and regulatory requirements. • Evaluate the financial impact of program changes, quality initiatives, and value‑based arrangements. • Ensure analyses align with CMS and state Medicaid guidelines. • Develop, maintain, and enhance actuarial models used for Medicaid analysis. • Validate data sources and ensure accuracy, consistency, and reasonableness of results. • Apply actuarial judgment in selecting assumptions and methodologies under guidance from senior staff. • Partner with Finance, Network, Clinical, and Operations teams to support Medicaid initiatives. • Communicate analytical results clearly to non‑actuarial stakeholders. • Respond to ad-hoc data requests and analytic questions related to Medicaid performance.

• 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