Job Description

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 field based position is accountable for the assessment and case management of Dual Special Needs members using established guidelines to ensure appropriate level of care as well as developing a member centric plan of care.

What You'll Do

• Assesses patient's clinical needs against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs.

• Evaluates the necessity, appropriateness and efficiency of services provided.

• Develops, coordinates and assists in implementation of members- individualized plan of care.

• 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.

• Documents accurately and comprehensively based on the standards of practice and current organization policies.

• Provides field based and/or telephonic case management activities specific to the Dual Special Needs program.

What You Bring

Education/Experience:

• Requires a High School diploma or GED. Bachelor's degree from an accredited college or university preferred.

• Requires a minimum of three (3) years broad clinical experience.

• Requires a minimum of three (3) years experience in home care, discharge planning, or case management. Preferably with the elderly frail population.

• Requires a minimum of three (3) year experience in the health care delivery system/industry.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ SW/RN/LPN License Required

Knowledge:

• Requires strong knowledge of the standards of practice for case managers.

• Requires strong knowledge of managed care principles and concepts including Health Plan Effectiveness Data and Information Sheet (HEDIS).

• Required knowledge of medical terminology.

• Prefers knowledge of managed care principles.

• Prefer experience with elderly frail population

Skills and Abilities:

• Requires strong organizational skills.

• Requires strong oral and written communication skills.

• Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)

• Requires good problem solving and conflict resolution skills.

• Requires good presentation skills.

• Requires ability to work with limited daily supervision

Travel :

• This is a field based position, daily local travel is required.

• Requires a car with valid New Jersey State License and Insurance

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:

$63,000 - $84,420

​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:

• 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.