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

The position is responsible for leading the managed long term support and services program clinical care team in a hands-on manner to provide exceptional service to the customer and contain medial claims cost. This is accomplished through active involvement and leading of the day-to-day operations of a clinical care team and ensuring staff is consistent with corporate policies and procedures and are compliant with contractual, state and federal guidelines. Serves as a medical resource to members and providers, and non-clinical staff.

What You'll Do

*The role is mostly remote, with field requirements in support of business needs. The role supports Care Managers in the field and specialized client visits.

Responsibilities:

• Supervises, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
• Continuously evaluates workflow issues and seek to improve processes that impact the managed long term support and services department.
• Coordinates data collection, reviews compliance reports and identifies opportunities for service improvements.
• Recommends, develops and implements department polices and procedures and interfaces with other areas to insure consistent applications.
• Liaison between Medical Directors and staff.
• Develops and monitors goals for staff and provides ongoing feedback and coaching.
• Conducts performance reviews on an annual basis and administers salaries for the staff.
• Directs the employment activities of the office that include staffing, development, and training.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.
• Performs the operational duties of a specific clinical care team.
• Ensures an atmosphere within the team, which fosters open communication, teamwork, ownership, and empowerment to make decision.
• Develops key performance indicators to evaluate level of service for internal and external customers.
• Acts as technical expert and reference point for difficult and complex matters.
• Facilitates the creation of service and processing innovations within the team. Shares innovations with other teams and market divisions.
• Assists in preparing and monitoring the budget to ensure administrative cost objectives are met. Identifies and implements cost saving/revenue generating opportunities.
• Interprets and executes policies for the team.
• Participates in special projects initiated by the Plan.
• Assists Manager in coordinating regulatory, quality and accreditation activities.
• Represents the Plan with external customers, providers and agencies.
• Represents the department on internal committees

What You Bring

Individuals who directly supervise Managed Long Term Support and Services Staff must have at least one of the following qualifications:

• A bachelor's degree (or higher) in a health related field and licensure as a health professional (RN. LSW)
• Certification as a case manager
• Professional certification in a clinical specialty and at least three years experience as a case manager

Individuals who supervise clinical staff must have at least one of the following qualifications:

• A bachelors degree in a health related field or
• Related work experience in the healthcare industry.

Additional Experience:

• Requires two (2) - four (4) years acute healthcare experience.
• Prefers one (1) year experience as a supervisor.
• Prefers one (1)- three (3) years experience in the health insurance industry.

Additional licensing, certifications, registrations:

Every member-facing employee of the MLTSS team, whose job duties may require them to enter a member’s place of residence(*), must be fully vaccinated. Upon hire, employee must provide their official CDC COVID-19 Vaccination Record Card, indicating full vaccination status(**) prior to their start date, unless a reasonable accommodation is requested and approved.

(*) Our members’ places of residence may include: their homes, assisted or nursing care facilities, or any other care establishment in which a member may reside.

(**) According to the CDC, a person is considered fully vaccinated two weeks after receiving the second dose of a two-dose series COVID-19 vaccine or two weeks after the first-dose of a single-dose vaccine. To remain fully vaccinated, employees will be expected to get booster shots pursuant to guidelines issued by the FDA and CDC.

• Active Unrestricted NJ RN/SW License Required

Knowledge:

• Requires knowledge of Utilization Management (UM) and managed care principles as they relate to the CCM process and Elderly Frail /Managed Medicaid Population based CM
• Requires knowledge of the 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 Mandates and Regulations, including HIPAA and HCQA.
• Requires knowledge of regulatory bodies and their processes including HCFA and DOBI.
• Requires knowledge of NCQA and URAC accreditation criteria related specifically to UM/DM and Case Management.
• Requires knowledge of community health resources.

Skills and Abilities:

• Requires the ability to express thought clearly and concisely both orally and written.
• Requires the ability to obtain the skills possessed by the team members and system technical competence.
• Require the ability to effectively lead team members in diversified tasks.
• Requires excellent organizational skills.
• Requires excellent presentation skills.
• Requires the ability to think analytically and to report findings in an accurate manner.
• Requires knowledge of computers and their related software packages.

Travel :

• Minimum local travel required

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.

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:

$87,300 - $119,070

​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.