• Guide healthcare providers through the reimbursement process for including prior authorizations, appeals, and benefits verification • Work with insurance companies, payers, and third-party administrators to address coverage issues and ensure timely access to therapies • Provide education regarding insurance benefits and financial assistance programs • Ensure all reimbursement activities comply with federal and state regulations, as well as organizational policies • Maintain accurate and detailed documentation of all reimbursement activities, including case notes, payer communications, and patient outcomes • Work closely with cross-functional teams in a compliant manner • Provide insights to internal teams on reimbursement trends and challenges to inform strategic decision-making • Educate healthcare providers and internal teams on reimbursement processes, payer requirements, and available patient support programs • Stay up to date on changes in reimbursement policies and regulations to provide accurate guidance • Identify systemic issues in the reimbursement process and recommend solutions to improve efficiency and patient outcomes

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 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. 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. - 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. - Schedule: 8- or 10-hour workday Monday through Friday varying between 8am and 11pm. Disclaimer: 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. 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.

• Manage a team of District Asset Protection Leaders (DAPLs) • Provide oversight to enterprise Asset Protection objectives and programs to ensure compliance. • Hiring, training, and developing a best-in-class Asset Protection team. • Forge strong business partnerships with Regional Directors of Operations. • Analyze market trends to create market-specific shrink mitigation tactics. • Monitor the execution of Asset Protection strategies and key performance indicators. • Report to the Divisional Asset Protection Director.

• Ensure effective execution of Sanofi strategies and tactics within assigned geographic area by developing effective business plans to execute selling strategies that are consistent with corporate brand and marketing plans and are tailored to geography and customer context. • Identify key decision makers for the use of Sanofi products and conduct customer meetings within assigned territory. • Demonstrate advanced ability to ask strategic, insightful questions to obtain information on customer needs from all stakeholders in hematology accounts, using the insights to position current promoted Hematology brands and collaborate with customers on a customized strategy. • Review and analyze market/customer data to support and execute strategic planning. • Review and analyze data/systems/processes to identify and create business opportunities and to improve tactical implementation of strategic goals. • Collaborate closely with cross functional team members to identify and resolve customer needs appropriately and with a high sense of urgency. • Conduct formal and informal presentations and convey complex hematology clinical information fluently to Institutional based physicians in large academic centers and hospitals or large group practices/groups, in a professional, compliant, and effective manner. • Demonstrates deep marketplace, therapeutic, product and disease expertise based on thorough understanding of rigorous scientific principles and data, including mechanism of action, indications, efficacy, safety, etc. • Provide key market insights and field feedback to home office. • Understand and apply knowledge of health care industry, trends, applicable laws and regulations, market conditions, and the market access environment (including but not limited to pharmacy-economics, payer/reimbursement landscape and patient flow/influence between institutions and community practices) and analyze these factors in the development of business plans and in daily execution of sales calls within compliance guidelines. • Build and maintain strong professional relationships with physicians/HCPs office and hospital staff and others in the patient care continuum. • Coordinate with patient and provider services (Specialty Pharmacy, Specialty Distributor, Patient Services) to assure complete patient care (diagnosis through completion of treatment). • Be responsive to the needs of providers and patients, understanding the importance of urgent and timely resolution. • Foster team effectiveness and accomplishment of shared goals by sharing knowledge, experience, and information between and amongst partners.