This position is responsible for performing RN duties for the Primary Nurse population using established guidelines to ensure appropriate level of care, as well as, planning for the transition to the continuum of care and developing a member centric plan of care. Primary Nurses will outreach to high risk members and will work to engage members in preventative care opportu

This field based position is responsible for performing assessments of members using established guidelines to ensure appropriate level of care and develop a member centric plan of care. Job Description Responsibilities Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members'

This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized. Responsibilities Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members

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. Responsibilities Assesses patient's clinical needs against established guidelines and/or standards to ensure that the services provided are medica

This senior analyst position within the Treasury Department will be responsible for conducting one or more major cash management activities. Responsibilities include cash management, liquidity projections, treasury operations, bank relationship management, cash accounting, account reconciliations, short term investing, short term borrowing and payments. The Treasury Analy

The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, diseas

This position is responsible for overseeing contracts between hospitals in the Select Hospital Network or ancillary contracts (i.e. SNF's Sub acute, Home IV, etc.) and Horizon Blue Cross Blue Shield, and for ensuring that the contractual arrangement is fulfilled. Accountability's may include developing, negotiating and managing the ancillary contracting arrangements. In a

The Analytics Analyst III will partner with multiple customers to provide more complex resolutions to analytics/data problems (i.e. linear models, pattern analysis, directional modeling, etc.) that require a more detailed and deeper study of situational factors, gathering information from several sources, and providing reporting analysis deliverables (i.e. tables, visual

The Analytics Analyst III will partner with multiple customers to provide more complex resolutions to analytics/data problems (i.e. linear models, pattern analysis, directional modeling, etc.) that require a more detailed and deeper study of situational factors, gathering information from several sources, and providing reporting analysis deliverables (i.e. tables, visual

Responsible for the general operational oversight of multiple disciplines/units to ensure enterprise and divisional performance goals are achieved. Job Responsibilities Direct staff to ensure overall client satisfaction and appropriate level of service delivery. Develop and monitor goals for staff and provide ongoing feedback and coaching. Manage staff, including individu

Under general supervision, responsible for producing reports from various sources to provide the department /division with actionable information or business intelligence. This is an intermediate level position performing basic assignments, and may require guidance. Responsibilities Evaluate, write, and present utilization and cost containment reports. Determine or agree

The Data Analyst leads the technology process for the end to end Risk Adjustment Processing System (RAPS) and Encounter Data Processing System (EDPS) data flow and works within key regulator guidelines for acceptable data submission. Using SQL and SAS programs lead the gathering of data for submissions Risk Adjustment. As the senior analyst of data, will be responsible fo

The Identity and Access Management (IAM) Engineer will collaborate cross functionally with Security Architects, Senior Infrastructure Analysts, and Senior Application Developers to provide a stable WAM environment by applying new and best practices in Identity and Access Management and Customer IAM technologies to support business applications. This position will be respo

This position is responsible for the ability to understand and abide by Federal Centers for Medicare and Medicaid Services guidance. Fast paced environment with frequent priority changes. Organization and follow up abilities will be critical. Policy and reconciles daily systemic eligibility discrepancies. Responsibilities Reconciliation of all daily, weekly and monthly Me

Responsible for conducting file audits for all areas of clinical operations. These audits review daily business practice compliance to regulatory compliance relative to NCQA, URAC and CMS. Responsibilities Conduct quarterly file audits for all lines of business against business Process Flows to determine compliance with regulatory standards according to NCQA, URAC and CMS