RN, Data Analyst

Horizon Blue Cross Blue Shield NJ; New Jersey; On-site; USD 79,000 - 106,000; Full time

Benefits offered by this job

Comprehensive 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, based in Newark, NJ, is seeking a role focused on stop loss risk management activities and coordinating risk oversight with care delivery teams. The ideal candidate will excel at managing high-risk patient care and have a solid understanding of healthcare delivery systems.

This full-time position offers the chance to work with care management to identify high-risk patients, assess clinical needs against guidelines, and engage claimants in care

Qualifications

• Minimum high school diploma or GED.
• Prefer an Associate's or Bachelor's degree in nursing or a health-related field.
• Active NJ Registered Nurse License required.

Responsibilities

• Identify potential high-risk patients with care management.
• Assess patients' clinical needs against guidelines.
• Engage high-risk claimants in care management protocols.
• Coordinate with sales and account management for engagement.
• Coordinate supporters for high-risk patients.
• Use reporting tools to assess risk on medical and pharmacy claims.
• Ensure care management protocols for members outside service areas.
• Help evaluate risks in existing and potential stop loss groups.
• Collaborate with pharmacy management on specialty drug usage.
• Analyze variances and participate in quality improvement programs.

Skills

Clinical experience

Healthcare payer experience

Nursing background

Risk management

Education

Associate's or Bachelor's degree in nursing or health-related field

Job description

About This Role

This position is responsible for focusing on stop loss risk management activities and coordinating risk oversight with care delivery related areas of the company. It is ideal for individuals who are skilled in managing high-risk patient care and have a strong understanding of healthcare delivery systems.

Highlights

• Pay: $79,100 - $105,945/year
• Location: Newark, NJ
• Schedule: Full-time

What You'll Do

• Work with care management to identify potential high-risk patients.
• Assess patients' clinical needs against established guidelines.
• Engage potential high-risk claimants in care management protocols.
• Elicit support from sales and account management for care management engagement.
• Provide coordination for supporters of high-risk patients.
• Use reporting tools to assess risk on medical and pharmacy claims.
• Ensure care management protocols are maintained for members outside service areas.
• Assist in evaluating risks in existing and potential stop loss groups.
• Work proactively with pharmacy management for specialty drug usage.
• Analyze variances and participate in quality improvement programs.

Requirements

Education:

• Minimum high school diploma or GED
• Prefer an Associate's or Bachelor's degree in nursing or a health-related field

Experience:

• Minimum of two (2) years of clinical experience
• Minimum of three (3) years in the healthcare delivery system/industry
• Minimum of two (2) years of healthcare payer experience

Licenses & Certifications:

• Requires an active NJ Registered Nurse License
• Prefers pending or obtained certification in case management or other applicable clinical specialties

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

About Horizon Blue Cross Blue Shield of New Jersey is a leading healthcare provider committed to delivering exceptional patient care. With over 90 years of experience, they focus on improving healthcare quality, affordability, and member experience for over 3.5 million people.