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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.
This position serves as Horizons on-site clinical representative at the vendor location(s) or Horizon office based representative working collaboratively with the vendor management staff to ensure that exceptional service is provided to the customer. The incumbent facilitates the day to day coordination of the vendor(s) customer service clinical operations with Horizons clinical operations.
Responsibilities:
Acts as the clinical liaison between Horizon and the vendor to address day to day operational issues. Identifies and implements process improvements targeted to improve clinical operational efficiencies and delivery of customer service. Coordinates the delivery of clinical training and education to the vendor to ensure adherence to Horizon business and compliance requirements. Requests and evaluates Corrective Action Plans (CAP) for adequacy, works with vendor on required changes, communicates approval of CAP to the vendors, and monitors open CAP. Coordinates clinical guidance, coaching, refresher training and instructions to the vendor staff in order to improve performance. Standardizes workflows and business processes to ensure compatibility between the Plan and Vendor teams to increase efficiencies. Prepares status reports to keep Horizon management team apprised of daily operations, progress and issues. Assists in the timely resolution of escalated member issues. Facilitates the resolution of system problems, creating and tracking P-logs and escalate when required Facilitates meetings/workgroups to drive issue resolution and process improvements.
Disclaimer:
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.
Education/Experience:
High School Diploma/GED required. Bachelor degree in a health related field preferred or relevant experience in lieu of degree. Requires professional certification in a clinical specialty and least three years experience as a case manager. Requires four (4) years acute healthcare experience Prefers three (3) years experience as a supervisor. Prefers (3) years managed health care experience.
Additional Licensing, Certifications, Registrations:
Knowledge:
Requires knowledge of Case Management/Disease Management Standards of Practice. Requires knowledge of health care systems and medical documentation. Requires understanding of claims processing, contracting and enrollment. Requires knowledge of State and Federal Mandates and Regulations including HIPAA and HCQA.
Skills and Abilities:
Ability to express thought clearly and concisely both orally and written. Ability to effectively lead team members without direct authority in diversified tasks. Excellent organizational skills. Proven time management skills with the ability to manage multiple priorities. Exercise sound judgment and strong problem solving skills. Must be client focused with effective ability to empathize.
Travel:
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Salary Range: $86,000 - $117,390
This 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:
Disclaimer:
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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Horizon Blue Cross Blue Shield of New Jersey
tuition reimbursement
May 14, 2025