Jobs at Horizon Blue Cross Blue Shield of New Jersey

Process and evaluate prior authorization requests by phone and fax, determine medical necessity using clinical criteria, liaise with pharmacists and physicians to optimize formulary compliance, handle appeals/complaints, identify fraud, produce reports, support pharmacy programs (Medication Therapy Management) and ensure regulatory turnaround times and departmental quality metrics are met.

Conduct medical appeals and utilization management reviews, ensuring regulatory compliance and timeliness. Review medical records, coordinate with Medical Directors, IURO/IRO and legal as needed, present cases to appeals committees, mentor appeals staff, provide on-call coverage, and support quality improvement and vendor/delegate oversight.

Lead sales enablement and customer/broker marketing for multiple business segments, develop go-to-market and open enrollment strategies, manage budgets and reporting, coordinate with enterprise marketing on creative and KPIs, run advisory board and event presence, maintain broker-facing content and sales assets, and support cross-functional execution to meet membership and revenue goals.

Perform internal and external vulnerability assessments, manage vulnerability scanning programs, prioritize and track remediation with technology teams, produce metrics and executive reports, support threat intelligence and threat hunting, maintain policies and controls for audit/compliance, and drive continuous improvement to reduce organizational cyber risk.

Lead enterprise process improvement initiatives using Lean, DMAIC, and Six Sigma; perform detailed process analysis, data-driven ROI modeling, value stream mapping, and statistical analysis; coach and mentor analysts, develop control plans, partner with finance and stakeholders, and deliver measurable operational and financial improvements.

Performs behavioral health utilization and care management: assesses clinical needs, ensures appropriate level/length of stay, coordinates transition and services across providers, documents care, monitors outcomes, and advocates for members to optimize cost-effective care.

The Digital Products Reporting Manager will lead and develop reporting and analytics strategies for digital products, present insights to stakeholders, and analyze performance and trends to enhance user experiences and project outcomes.

Serve as BCM subject matter expert to configure Fusion tool, develop recovery strategies, maintain BCM plans, run Business Impact Analyses, lead training/exercises, support incident response, and report to senior management.

Lead and execute provider network contracting and negotiations for hospitals, physicians, and ancillary providers across Commercial, Medicare, Medicaid, DSNP, MLTSS and casualty lines. Prepare rate proposals with Medical Economics and Actuary, ensure accurate contract implementation and system configuration, analyze contracts to drive cost savings, maintain contract templates and compliance, support value-based payment initiatives, and collaborate cross-functionally to integrate network strategy with enterprise objectives.

Lead and execute provider network contracting and negotiations across Commercial, Medicare, Medicaid, DSNP, MLTSS and casualty lines. Prepare rate proposals with Medical Economics and Actuary, ensure accurate contract implementation and system configuration, analyze contracts for cost savings, maintain contract language and templates, collaborate with Legal/Compliance and internal partners, and support value-based payment initiatives and network strategy.

Lead Quality Management clinical operations and performance reporting for Horizon Government Programs. Oversee HEDIS, Stars, and NCQA-related audits and initiatives, develop policies and HEDIS training, manage staff and provider relationships, drive pay-for-performance and quality improvement projects, and collaborate across departments to improve provider and plan quality outcomes.

Performs utilization management nursing: assesses medical necessity and length of stay, coordinates care transitions, monitors outcomes, negotiates out-of-network services, documents per policy, and collaborates with members, families, providers, and multidisciplinary teams to ensure high-quality, cost-effective care.

The role involves conducting data analysis for process improvement, leading initiatives, mentoring staff, and developing business cases using ROI models to enhance efficiency and reduce costs.

Manage and oversee federal, state, and local tax compliance and accounting for GAAP and statutory reporting. Lead tax provision preparation, multi-state filings, audits, nexus determinations, information reporting, process improvements, and supervise tax analysts. Ensure internal controls (MAR) and review external provider deliverables prior to Director-level review.

Lead a marketing communications team to design, plan, and execute integrated, omni-channel campaigns aligned with business goals. Manage budgets, vendors, analytics (Adobe Analytics, CRM), reporting, and compliance while coordinating cross-functional stakeholders and optimizing campaign performance.

Support commercial trend forecasting and pricing by applying actuarial and statistical methods. Evaluate benefit and cost‑sharing changes, model legislative impacts, run experience studies, prepare reports, and collaborate with stakeholders on actuarial projects and ad hoc analyses.

Lead business systems analyst responsible for eliciting, documenting, and translating complex business requirements for Blue Card/BCBSA initiatives. Coordinate solution design, testing (SIT/UAT/Model Office), production support, and stakeholder communications. Manage traceability, impact assessments, release readiness, and mentor junior analysts while partnering with NASCO/BCBSA and cross-functional teams to deliver modernization and operational improvements.

Lead a small growth operations team to manage enterprise sales pipeline, enforce BANT qualification, maintain CRM and forecasting discipline, build and refine lead scoring in Salesforce, generate executive meetings, coordinate cross-functional deal execution, leverage AI for prospecting, and coach junior team members to improve pipeline conversion.

Support premium rate development and pricing for large group, individual, and small group markets. Perform pricing analyses, financial modeling, experience studies, regulatory and Mental Health Parity reviews, and rate filings. Collaborate with actuarial, product, finance, and regulatory teams to analyze data, assess legislative impacts, and produce reports and recommendations to support pricing strategy and regulatory compliance.

Perform advanced actuarial analyses, forecasting, pricing, and financial modeling using claims, membership, and utilization data. Develop reports and dashboards, support IBNR estimates, rate development, regulatory filings, and product pricing. Collaborate with business partners, present findings, and continue actuarial exam progression.