Care Specialist III

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

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. This position is accountable for the management of high risk level cases identified through the care management program to ensure effective implementation of interventions, and to ensure efficient utilization of benefits.

Requirements

High School Diploma/GED required.
Requires a minimum of three (3) years broad clinical experience.
Requires a minimum of two (2) years experience in home care, discharge planning and/or case management.
Requires a minimum of three (3) years experience in the managed care industry.
Active Unrestricted NJ SW License or New Jersey Certified Social Worker (CSW.) or New Jersey License Social Worker (LSW) or License Clinical Social Worker (LCSW) preferred.
Requires a car with valid New Jersey State License and Insurance for certain positions.
Requires strong knowledge of the standards of practice for case managers.
Requires strong knowledge of managed care principles and concepts including Health Plan.
Employer Data and Information Sheet (HEDIS).
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 good presentation skills.
Requires Project Management Skills
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Nice To Haves

Bachelor degree preferred or relevant experience in lieu of degree.
Prefers CCM certification.

Responsibilities

Conducts high-level assessment and planning for selected population-based members.
Collaborates with the member/family, physician and all members of the healthcare team, internal and external to this organization.
Coordinates the delivery of high quality, cost-effective care based on a customized population
Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
Interacts with the member/family, physician and healthcare team.
Utilizes 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.
Encourages member participation and compliance in the care management program efforts.
Utilizes population-based case management process for goal directed member/family care.
Documents accurately and comprehensively based on the standards of practice and current organization policies.
Interacts and communicates, either telephonically and/or on site striving for continuity and efficiency as the member is managed along the continuum of care.
Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Provides telephonic and/or field based population case management activities specific to the care management program.
Provides guidance and support to less experienced Care Specialists.
Acts as mentor / preceptor to new hires within the department
Performs user acceptance testing on any process, program and system changes or enhancements, as indicated by leadership
Contributes to overall program execution and success, which includes; active participation in strategic and tactical planning, identifying process improvements as well as creating, developing and implementing revisions.