Jobs at Horizon Blue Cross Blue Shield of New Jersey

Lead development, negotiation, management, and implementation of provider contracts for hospitals, physician groups, and ancillary providers across fee-for-service and value-based payment models. Oversee contract loading, network adequacy, rate proposals, regulatory compliance, cost analyses, team leadership, vendor/stakeholder collaboration, and drive initiatives to reduce medical cost and improve network performance.

Leads risk adjustment operations by coordinating analytics, reporting, process improvement, and alignment across business units. Manages operational status tracking, presentations, special projects, issue resolution, and implementation of solutions related to product development, network design, and pricing. Provides actionable insights to leadership and manages, develops, trains, and evaluates staff.

Performs behavioral health utilization and care management, assessing medical necessity, coordinating services across providers and care settings, monitoring outcomes, advocating for members, documenting care, and supporting quality improvement. The role requires collaboration with patients, families, physicians, hospitals, and multidisciplinary teams to ensure appropriate, cost-effective care throughout the continuum.

Performs nursing-based utilization and care management for members, assessing medical necessity, level of care, and length of stay. Coordinates services among patients, families, providers, hospitals, and multidisciplinary teams; supports transitions across the care continuum; monitors outcomes, resource use, and service appropriateness; negotiates out-of-network fees; documents care activities; and participates in quality improvement efforts.

Performs inpatient utilization and care management for members, assessing medical necessity, level of care, length of stay, and service effectiveness. Coordinates care transitions and resources among patients, families, physicians, hospitals, and multidisciplinary teams. Supports cost-effective care, negotiates out-of-network services when appropriate, documents assessments, promotes member participation, and contributes to quality improvement. Requires an active unrestricted New Jersey RN license and at least two years of clinical experience.

Leads enterprise public website application strategy, development, governance, modernization, and operational performance. Manages application roadmaps, software lifecycle practices, Agile teams, production support, service levels, vendors, budgets, security, accessibility, analytics, and continuous optimization. Oversees up to approximately 50 employees and contingent resources while partnering with business, infrastructure, security, architecture, engineering, legal, and procurement stakeholders.

Handles utilization management medical appeals, assessing clinical appropriateness, reviewing records, coordinating medical director and external reviews, and ensuring regulatory compliance. Resolves complex and high-priority cases, presents appeals to committees, supports vendors and internal stakeholders, documents decisions, and participates in quality improvement. Provides clinical liaison support, mentoring, special project assistance, and scheduled 24/7 on-call coverage, including required weekends and holidays.

Provides pediatric RN case management by assessing medical necessity, coordinating care across providers and settings, supporting transitions of care, monitoring outcomes, advocating for members and families, documenting services, and promoting cost-effective, guideline-based treatment. Collaborates with multidisciplinary teams, evaluates utilization and quality, negotiates out-of-network services when appropriate, and supports member participation in care and disease management programs.

Performs utilization and care management for health plan members by assessing medical necessity, coordinating services across care settings, monitoring outcomes, advocating for members, documenting care, and supporting cost-effective, quality-focused transitions across the continuum of care.

Leads Managed Long-Term Services and Supports operations across home-, community-, and facility-based care. Oversees strategy, care coordination, regulatory compliance, audits, program integrity, provider collaboration, performance analytics, process improvement, and authorization support. Develops policies, manages operational risks, represents the program in regulatory workgroups, and leads team training, performance management, and talent development.

Supervises accounting activities including reconciliations, journal entries, financial close, variance analysis, reporting, controls, and audit support. Resolves discrepancies, partners cross-functionally on accounting initiatives, supports system implementations and process improvements, and leads accounting staff through coaching, workload management, and performance development. Ensures compliance with accounting policies, internal controls, GAAP, regulatory requirements, and reporting standards.

Performs utilization and care management for members by assessing clinical needs, evaluating medical necessity and level of care, coordinating services and transitions, advocating for patients and families, and monitoring outcomes. Collaborates with providers and multidisciplinary teams, documents care accurately, supports quality improvement, and promotes appropriate resource utilization. The role requires an active unrestricted New Jersey RN license, nursing education, clinical experience, and scheduled weekend and holiday coverage.

Coordinates provider-network strategy initiatives, compliance activities, accreditation requirements, special projects, and process improvements. Develops action plans to improve CAHPS, HEDIS, and office manager satisfaction scores; supports physician communications, education materials, RFP responses, and product implementations. Facilitates cross-functional teams, monitors network consistency, addresses deficiencies, and ensures compliance with state, federal, and accrediting standards.

Supports the No Surprises Act actuarial workstream through forecasts, reserves, liability monitoring, profitability analyses, financial reporting, and data quality improvement. Partners with actuarial, finance, operations, legal, and vendor teams to validate data, document methodologies, monitor regulatory developments, and communicate financial trends, risks, and recommendations. The role also supports ad hoc actuarial projects, process improvements, and peer coaching.

Supports actuarial and analytics initiatives through data mapping, correlation analysis, dataset enhancement, reserve calculations, pricing and experience analysis, financial projections, and quantitative actuarial work. Provides technical and analytical support under supervision while using Excel, VBA, SQL, and potentially SAS to generate insights and support decision-making.

Leads enterprise business process improvement initiatives focused on cost reduction, efficiency, and customer experience. Uses Lean, DMAIC, Design for Six Sigma, value-stream mapping, statistical analysis, ROI modeling, and control plans. Oversees analyses, mentors Lean and Green Belt candidates, manages project risks and deliverables, develops business cases, and collaborates with business partners and subject matter experts to deliver sustainable operational and financial improvements.

Interprets, documents, and validates group health benefit information for new and existing clients. Reviews benefit designs, coordinates internal implementation and coding, confirms system testing, maintains audit records, troubleshoots enrollment, claims, and billing issues, and supports client meetings, enrollment sessions, training, and pre-implementation audits. Builds relationships with account management and internal teams to implement benefit changes and new lines of business.

Supports account management teams serving State Health Benefits Program stakeholders. Provides expertise in underwriting, ancillary products, benefit design, billing operations, forecasting, plan implementations, vendor integrations, and health insurance market dynamics. Maintains billing records and stakeholder databases, resolves billing discrepancies, translates legislation into business requirements, supports retention and growth strategies, and trains new staff on the market. Requires extensive group health experience and knowledge of health plans, claims operations, pricing, and underwriting.

Manages complex national large-group health insurance accounts, focusing on retention, renewals, contract negotiations, product expansion, client relationships, service performance, and issue resolution. Advises clients, brokers, trustees, and consultants; coordinates with internal teams and vendors; delivers reporting, workshops, and regulatory updates; and makes financial, operational, and service-related decisions. The role requires national travel, strong negotiation and presentation skills, health insurance knowledge, and a New Jersey Health/Life license.

Coordinates care management for pediatric members across the healthcare continuum, monitoring services, outcomes, utilization, and cost effectiveness. Advocates for members and families, collaborates with providers and multidisciplinary teams, documents care, supports quality improvement, and applies clinical guidelines and motivational interviewing. Mentors staff, contributes to committees and projects, presents reports, and supports user acceptance testing for medical management systems.