Care Manager I, Specialty Programs

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

10h

About The Position

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. 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.

Requirements

Requires a license as an RN, or Bachelor degree in social work, health or behavioral science.
Requires a minimum of three (3) years’ experience serving members with special needs.
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.
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.
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Nice To Haves

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

Responsibilities

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 escalate as appropriate to internal physician resources.
Complete other assigned functions as requested by management.