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
This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed.
What You'll Do
Responsible for managing inbound clinical calls and maintaining a direct case management caseload. Performs telephonic clinical triage, risk assessment, care coordination, member education, and referral management. Conducts proactive outbound outreach to members, caregivers, providers, and community resources to support engagement, address barriers to care, facilitate transitions of care, and improve health outcomes through comprehensive case management services.
Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided.
Coordinates and assists in implementation of plan for members.
Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, 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.
Monitors patient'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.
Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
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.
Acts as subject matter expert for respective area for projects.
May assume leadership type activities in team leads absence.
Represent clinical teams within committee meetings
Present reports required at committee meetings.
Subject matter expert for user acceptance testing for medical management system.
Addendum for Horizon Clinical Advocate Roles:
Outreaches to members identified by Horizon as needing Clinical Advocate services.
Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment.
Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques.
Becomes knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language.
Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional.
Schedule: 8- or 10-hour workday Monday through Friday varying between 8am and 11pm.
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.
What You Bring
High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Requires a minimum of two (2) years clinical experience.
Requires minimum of two (2) years’ experience with health care payer experience.
Addendum for Horizon Clinical Advocate roles:
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.
Requires knowledge of hospital structures and payment systems.
Requires working knowledge of case/care/disease management principles.
Requires working knowledge of operations of utilization, case and/or disease management processes.
Requires knowledge of health care contracts and benefit eligibility requirements.
Requires mentoring knowledge on the operations of utilization/case/disease management.
Addendum for Horizon Clinical Advocate roles:
Requires ability to be an empathetic critical thinker.
Requires excellent communication and organizational skills and a high tolerance for ambiguity.
Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization.
Experience in active listening and motivational interviewing strongly preferred.
Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills.
Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion.
Skills and Abilities:
Adaptability/Flexibility
Analytical
Compassion
Interpersonal & Client Relationship Skills
Information/Knowledge Sharing
Judgment
Listening
Planning/Priority Setting
Problem Solving
Team Player
Time Management
Written/Oral Communication & Organizational Skills
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
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:
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.
