Jobs at Horizon Blue Cross Blue Shield of New Jersey

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.

Manages a team handling escalated complaints and appeals from regulators, executives, public affairs, and legislative offices. Ensures timely, high-quality resolutions; develops training and corrective action plans; monitors service metrics and SLAs; maintains administrative policies; leads process improvements; and represents the organization with regulatory agencies. Requires healthcare or insurance operations knowledge, regulatory compliance expertise, leadership, analytical, communication, and problem-solving skills.

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.

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.

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.

Supports new and existing health insurance accounts by partnering with Sales, brokers, and internal teams. Responsibilities include resolving complex service issues, administering enrollment and account documentation, coordinating group implementations and renewals, maintaining account records, validating information, supporting retention and growth, and identifying process improvements. The role requires health insurance experience, strong customer and stakeholder relationship skills, Microsoft Office proficiency, and a New Jersey health and life insurance license or ability to obtain one.

Supports provider data management and Government Programs provider systems by maintaining accurate provider files, resolving data errors, investigating data integrity incidents, developing system specifications and user testing criteria, improving procedures, producing quality and production reports, conducting vendor audits, and representing the department on committees. Requires healthcare provider data management experience, analytical skills, attention to detail, and proficiency with Microsoft Office.

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.

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.

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.

Support actuarial and data analytics for risk-adjusted lines (ACA, Medicare Advantage, Medicaid). Analyze risk scores, financial impacts, and performance metrics; produce projections (CMS-HCC, HHS-HCC), inform risk adjustment strategy, reporting, pricing, and forecasts; evaluate vendor performance and intervention ROI; support ACA pricing and MA bid submissions.

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.

Performs actuarial pricing, underwriting support, reserving, forecasting, trend analysis, and risk assessment for Stop Loss and Level Funded products. Develops and supports pricing models, analyzes financial and utilization data including IBNR, contributes to business planning, and communicates actuarial findings to business partners. The role supports new business and renewal decisions while identifying opportunities and minimizing financial risk.

Manage and retain public-market accounts by handling contract renewals, negotiating terms, selling additional product lines, and developing new business. Provide client workshops on enrollment and claims, advise on regulatory impacts, modify contracts as needed, and make binding financial and service decisions. Requires travel across New Jersey and coordination with stakeholders.

Lead design, development and enhancement of health insurance products across market segments. Serve as product SME, conduct market/research/competitive analysis, monitor product performance and profitability, support cross-functional teams (Sales, Underwriting, Actuarial, IT), manage product lifecycle and maintenance, present Consumerism products, and drive sales, utilization and retention plans.

Manage resolution of inadvertent/involuntary out-of-network billing disputes within regulatory timeframes: verify eligibility, research negotiation attempts, interact with providers/billers/attorneys, prepare written justifications, execute timely claim adjustments, track escalations (CMS/DOBI/DOL/Legal), perform root-cause analysis, and log cases via SharePoint/Blue systems.

Lead and supervise assigned internal audits and initiatives: develop scope and work programs, perform testing and analysis, document control issues, prepare reports, track remediation, and mentor staff while collaborating with management to improve internal controls.

Draft, review, negotiate, and manage commercial, vendor, finance, real estate, and Business Associate Agreements. Develop templates and contract tools, advise stakeholders on legal risks, train colleagues on contract best practices, report on BAA performance, support privacy incident response and data ethics, and recommend operational efficiencies.