Job Details

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.

Responsibilities

• Assesses patients 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 and outside the local area, and negotiates 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 patients 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.
• Acts as subject matter expert for projects and for the area of responsibility.
• Might assume leadership type activities in team leads absence.
• Represents clinical teams within committee meetings.
• Presents reports required at committee meetings.
• Serves as mentor/trainer to new RNs and other staff as needed.
• Subject matter expert for user acceptance testing for the medical management system.

Clinical Advocate Addendum

• 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.
• Advocates for members consistently throughout their health?care 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 a whole?person approach, eliminating homework or unnecessary burdens on the members to 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 8?am and 11?pm.

Education & Experience

• High School Diploma/GED required.
• Bachelors 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.

Licenses & Certifications

• Active Unrestricted NJ RN License or active Compact License required.
• CCM certification preferred for Clinical Advocate roles.

Knowledge & Skills

• Proficiency in the use of personal computers and supporting software in a Windows?based environment, including MS Office products (Word, Excel, PowerPoint, Outlook).
• Knowledge of hospital structures and payment systems.
• Working knowledge of case/care/disease management principles.
• Working knowledge of operations of utilization, case and/or disease management processes.
• Knowledge of health care contracts and benefit eligibility requirements.
• Mentoring knowledge on the operations of utilization/case/disease management.
• Ability to be an empathetic critical thinker.
• Excellent communication and organizational skills and a high tolerance for ambiguity.
• Ability to understand and communicate member benefits, claims and coordination focusing on advocacy principles and effective utilization.
• Experience in active listening and motivational interviewing strongly preferred.
• Strong analytical, critical thinking and interpersonal skills.
• Exceptional multi?channel communication and interpersonal skills, including the ability to explain complex concepts clearly with compassion.

Salary and Benefits

• Salary range: $77,900 $104,370.
• Comprehensive health benefits (Medical/Dental/Vision).
• Retirement plans.
• Generous PTO.
• Incentive plans.
• Wellness programs.
• Paid volunteer time off.
• Tuition reimbursement.

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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.