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Job description
About the Role
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.
What You'll Do
Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure.
Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider.
Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs.
Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness.
Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care.
Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
Encourages member participation and compliance in the case/disease management program efforts.
Documents accurately and comprehensively based on the standards of practice and current organization policies.
Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Serves as mentor/trainer to new RN's and other staff as needed.
Present clinical cases during audits conducted by external review organizations.
What You Bring
Education/Experience: Requires an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.
Requires a minimum of two (2) years clinical experience.
Experience with both acute and chronic conditions preferred.
Requires a minimum of three (3) years' experience in the health care delivery system/industry.
Experience with health care payer experience strongly preferred.
Additional licensing, certifications, registrations: Active Unrestricted RN License Required; NJ License Preferred Requires a valid Driver's License and Insurance.
Knowledge: Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, and PowerPoint) and Microsoft Outlook.
Prefers knowledge in the use of intranet and internet applications.
Requires working knowledge of case/care/disease management principles.
Requires working knowledge of operations of utilization, case and/or disease management processes.
Requires working knowledge of principles of utilization management.
Requires basic knowledge of health care contracts and benefit eligibility requirements.
Requires knowledge of hospital structures and payment systems.
Prefers understanding of fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
Skills and Abilities
Bi-lingual proficiency preferred.
Adaptability/Flexibility
Analytical
Compassion
Information/Knowledge Sharing
Interpersonal & Client Relationship
Sound decision making
Active listening
Organization
Planning/Priority Setting
Problem Solving/Critical Thinking
Team Player
Time Management
Written/Oral Communications
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
$79,100 - $105,945
Benefits
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 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 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.
About Us
We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.
Our Mission
We empower our members to achieve their best health.
Our Vision
We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.
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Worksite address
hopewell, NJ, 08525, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.