Care Manager I, Specialty Programs (Hunterdon & Somerset Counties)

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (NJ); On-site; USD 71,000 - 94,000; Full time

Benefits offered by this job

Health benefits

Retirement plans

Generous PTO

Incentive plans

Wellness programs

Paid volunteer time off

Tuition reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a Care Manager I - Specialty Programs to perform care coordination for specialty populations. The role ensures appropriate care levels and plans transitions across the continuum of care, guided by plan-based clinical practice guidelines.

The candidate will partner with members, families, physicians, and the healthcare team to meet needs, monitor utilization, and document activities accurately.

Qualifications

• Requires a license as an RN, or Bachelor degree in social work, health or behavioral science.
• Graduate level degree in Social Work or Health and Behavioral Science preferred.
• Minimum of three years' experience serving members with special needs.

Responsibilities

• Assess member's clinical needs against guidelines for specialty population-based members.
• Implement high quality, cost-effective care based on a population model of care.
• Collaborate with member/family, physicians, and healthcare team to meet needs and coordinate resources.
• Use care management process to plan, organize and implement interventions toward self-care and transition to independence.
• Monitor utilization to ensure care for mandated non-compliant members.
• Document accurately per standards of practice and policies.
• Evaluate care through problem solving and quality improvement.
• Monitor care activities across sites and networks for appropriateness and outcomes.
• Consult with internal stakeholders on complex cases and elevate to physician resources.
• Complete other assigned functions as requested by management.

Skills

Organizational skills

Communication skills

MS Office

Problem solving

NJ driver’s license

Education

RN license or BA in social work/health/behavioral science

Graduate degree in Social Work or Health & Behavioral Science preferred

Tools

MS Office (Excel/Access/Word)

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 Care Manager I - Specialty Programs is responsible for performing care coordination duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care for specialty populations. This position implements interventions to ensure efficient utilization of benefits.

What You'll Do

• Assess member's clinical need against establish guidelines and/or standards for specialty population-based members.

• Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan.

• Partner with the member/family, physician, and all members of the healthcare team to ensure the member's needs are met, internal and external to this organization. Advocate for the member among various sites to coordinate resource utilization.

• Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status.

• Ensure care for mandated non-compliant members through the monitoring of utilization.

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

• Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes.

• Monitor member's care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness.

• Consult with internal stakeholders on complex cases and elevate as appropriate to internal physician resources.

• Complete other assigned functions as requested by management.

What You Bring

Education/Experience:

• Requires a license as an RN, or Bachelor degree in social work, health or behavioral science.

• Graduate level degree in Social Work or Health and Behavioral Science preferred.

• Requires a minimum of three (3) years' experience serving members with special needs.

Knowledge:

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

• Requires strong knowledge of managed care principles.

• Requires strong knowledge of specialty population, as applicable.

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 a car with valid New Jersey State License and Insurance for certain positions.

Why Horizon?

At Horizon, you'll do meaningful work that directly improves lives-while being supported by a missiondriven 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:

$70,500 - $94,395

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.