RN Data Analyst - Care Risk & Outcomes

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

Benefits offered by this job

Health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Tuition Reimbursement

Job summary

Horizon BCBSNJ in New Jersey seeks a Nurse-focused Stop Loss Risk Manager to lead risk oversight for high-risk members within stop loss coverage. You will coordinate across care delivery, clinical guidelines, and payer partnerships to ensure medically necessary care.

The role emphasizes data-driven decision making with dashboards and reports, requires an active NJ RN license, 2+ years clinical experience, and 3+ years in health care delivery and payer environments.

Qualifications

• Requires an active NJ Registered Nurse License.
• Minimum two years of clinical experience.
• Minimum three years in health care delivery/industry.
• Two years in health care payer experience preferred.
• Advanced Excel, SQL or Tableau skills.
• Experience creating dashboards and reports.

Responsibilities

• Focus stop loss risk management activities on centralized team and coordinate oversight across care delivery.
• Identify high risk patients and assess clinical needs against guidelines to ensure medically necessary care.
• Engage sales, brokers and group customers to ensure care management involvement.
• Coordinate for supporters of high-risk patients, including families and employers.
• Use claims data to assess risk and monitor care management protocols across service areas.
• Evaluate risks in existing and prospective stop loss groups with UW.
• Support specialty drug usage optimization and site-of-service decisions.
• Communicate case management services to stop loss teams and other stakeholders.
• Identify and manage high-risk claimants within stop loss portfolios.

Skills

Clinical experience

Interpersonal skills

Cross-functional collaboration

Dashboard development

Education

NJ Registered Nurse License

Tools

Excel

SQL

Tableau

Job description

Horizon BCBSNJ in New Jersey seeks a Nurse-focused Stop Loss Risk Manager to lead risk oversight for high-risk members within stop loss coverage. You will coordinate across care delivery, clinical guidelines, and payer partnerships to ensure medically necessary care.

The role emphasizes data-driven decision making with dashboards and reports, requires an active NJ RN license, 2+ years clinical experience, and 3+ years in health care delivery and payer environments.