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
The position is responsible for leading a specific clinical care team in a hands-on manner to provide exceptional service to the customer and contain medical claims cost. This is accomplished through active involvement and leading of the day-to-day operations of a clinical care team and ensuring staff is consistent with Horizon's policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, as well as non-clinical staff.What You'll Do
Manages, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies and procedures.
Conducts continuous evaluation of workflows and seeks to improve processes that impact the department.
Coordinates data collection, reviews compliance reporting and identifies opportunities for improvements. Identifies and implements cost saving/revenue generating opportunities.
Serves as key liaison between Medical Directors, Management leadership, and staff. Also serves as a medical resource to members and providers, as well as non-clinical staff.
Develops key performance indicators to evaluate level of service for internal and external customers.
Acts as a subject matter expert for difficult and complex matters. Represents the Plan with external customers, providers and agencies. Represents the department on internal committees and participates in special projects.
Assists Manager in coordinating regulatory, quality and accreditation activities. Performs other duties as assigned by management.
Creates and champions an atmosphere within the team, which fosters open communication, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.
Manages, directs, and develops staff by providing feedback and coaching. Administers performance and salary reviews for staff. Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures. Assists in preparing and monitoring the budget to ensure administrative cost objectives are met.
What You Bring
Education/Experience:
Requires a Nursing degree or a Masters in a Behavioral health related field or a Bachelors in a health related field.
Requires a minimum of two years' full time acute healthcare/direct clinical care experience to the consumer.
Requires a minimum of one year direct supervisory experience or demonstrated supervisory experience leading teams in a matrix management environment.
Prefer certification as a case manager.
Prefer minimum of three years’ experience as a case manager.
Requires minimum of 12 months experience in a managed care setting or the health insurance industry.
Additional licensing, certifications, registrations:
Active Unrestricted NJ LCSW, LMFT, LPC, or RN/PT License Required
Medicaid Case Management Only: Active Unrestricted NJ LSW, LCSW, LMFT, LPC, or RN/PT License Required
Knowledge:
Requires knowledge of Utilization Management (UM) and managed care principles.
Requires knowledge of the Case Management/Disease Management Standards of Practice.
Requires knowledge of health care systems and medical documentation.
Requires knowledge of State Mandates and Regulations.
Requires knowledge of regulatory bodies and their processes.
Requires knowledge of NCQA accreditation standards.
Requires knowledge of community health resources.
Skills and Abilities:
Requires the ability to express thought clearly and concisely both orally and written.
Requires the ability to obtain the skills possessed by the team members and system technical competence.
Requires the ability to effectively lead team members in diversified tasks.
Requires excellent organizational skills.
Requires excellent presentation skills.
Requires the ability to think analytically and to report findings in an accurate manner.
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.
Travel % (If Applicable):
Travel required to other Horizon offices, provider locations and/or for oversight of remotely located workforce members in accordance with Company needs.
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:
$87,300 - $119,070This 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.
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What We Do
Horizon Blue Cross Blue Shield of New Jersey- the state’s largest and oldest health insurer - is a subsidiary of Horizon Mutual Holdings, Inc., a not-for-profit mutual holding company. Together with its affiliates, Horizon provides a wide array of medical, dental, vision and prescription insurance products and services. As New Jersey’ health solutions leader, Horizon is transforming healthcare by working with doctors and hospitals to deliver innovative, patient-centered programs that improve quality and lower costs. It is headquartered in Newark, NJ with offices in Wall and Hopewell, NJ. Horizon serves 3.7 million members including more than 1 million who rely on Medicaid for their health coverage.
