Jobs at Horizon Blue Cross Blue Shield of New Jersey

The Sales Executive IV drives new account sales across various markets, focusing on meeting sales targets and building relationships with clients and brokers.

The CPC Investigator conducts coding reviews, audits medical records, analyzes claims for fraud, and manages investigative activities related to healthcare operations.

Supervise and execute audits, ensuring quality and effectiveness of internal controls, while managing staff and providing strategic recommendations to management.

The Medical Director oversees provider education and performance management initiatives, cultivating relationships to support quality outcomes and value-based care goals, while leading a team and refining strategies for collaboration and care delivery innovation.

The Paralegal III provides litigation and transactional support, conducts legal research, prepares documents, and collaborates with attorneys and departments.

Support actuarial decision-making through trend analysis, forecasting, and modeling for ACA, Medicare Advantage, and Medicaid. Perform risk score projections (CMS-HCC, HHS-HCC), financial and utilization reporting, vendor performance analysis, and support pricing, rate filings, and MA bid submissions.

Performs utilization management RN duties: assess medical necessity and appropriateness of care, coordinate member care across settings, implement care plans, document outcomes, communicate with multidisciplinary teams, and support cost‑effective, quality care transitions. Requires periodic weekend/holiday coverage.

Performs utilization management RN duties: assesses clinical need against guidelines, evaluates medical necessity and efficiency, coordinates care transitions, monitors services and outcomes, documents per standards, communicates with multidisciplinary teams, advocates for members, and participates in quality improvement and case/disease management.

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.

Investigate, research, and resolve member and provider complaints using the IMAC database. Ensure state timing and compliance, compile monthly/quarterly reports, follow up with internal teams, and draft resolution letters. Support monthly reporting and other duties as assigned.

Responsible for assessing patients' clinical needs, coordinating care, and ensuring appropriate services while advocating for members in the healthcare continuum.

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.

Provide RN case management for pediatric members: assess clinical needs, develop and coordinate individualized care plans, manage transitions across the continuum, monitor outcomes, collaborate with providers and families, document per policy, close gaps in care, and mentor/train staff.

Lead enterprise change management and organizational readiness for operational and technology transformations. Develop and execute change strategies, stakeholder engagement and communication plans, readiness assessments, release planning, risk mitigation, governance support, adoption measurement, and continuous improvement to ensure successful implementation and sustainable adoption.

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 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.

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.

Performs clinical assessments for PCA and MDC services to determine medically appropriate care and authorization. Coordinates care with members, families, physicians and multidisciplinary teams, documents thoroughly, monitors outcomes, refers to MLTSS as appropriate, educates members about SNP, and supports MLTSS case management and home care assessments when needed.

Lead strategic direction and operational delivery of the MLTSS program, ensuring regulatory compliance, high-quality member-centered care across settings, provider and stakeholder collaboration, data-driven performance management, and people leadership to drive continuous improvement and program integrity.