RN, Data Analyst

Horizon Healthcare Services•Newark, NJ

About The Position

This position focuses stop loss risk management activities on the centralized stop loss team and coordinates risk oversight with care delivery areas of the company. It helps ensure care is coordinated across the company and throughout the care delivery system for high-risk members of groups with stop loss coverage underwritten by Horizon BCBSNJ. The role applies established guidelines to ensure appropriate levels of care and to plan transitions of care. The position identifies and manages high-risk claimants in established and prospective stop loss customers, assesses clinical needs against established guidelines, and supports care management engagement. It uses medical and pharmacy claims reporting and risk-identification tools, collaborates with internal teams and external stakeholders, and contributes to quality improvement to enhance member outcomes. The role also supports appropriate specialty drug use and care delivery, including use of resources outside Horizon BCBSNJ's service area when appropriate.

Requirements

High school diploma or GED required.
Minimum of two years of clinical experience.
Minimum of three years of experience in the health care delivery system or industry.
Minimum of two years of health care payer experience.
Active New Jersey Registered Nurse license.
Understanding of health and prescription insurance products, contracts, and benefits eligibility.
Understanding of health delivery systems and professionals.
Understanding of case, care, or disease management principles.
Strong interpersonal skills and demonstrated ability to work across divisions and with external stakeholders.
Proficiency using personal computers and supporting software in a Windows-based environment, including MS Office (Word, Excel, PowerPoint, and MS Project) and Lotus Notes.

Nice To Haves

Associate's or bachelor's degree (or higher) in nursing or a health-related field, or graduation from an accredited diploma nursing school.
Advanced Excel, SQL, or Tableau skills.
Experience creating dashboards and reports.
Pending or obtained certification in case management or other applicable clinical specialties.
Understanding of stop loss reporting tools and requirements.
Understanding of risk mitigation, high-claimant detection, engagement, and management.

Responsibilities

Work with care management and care delivery functions to identify potential high-risk patients in new business and renewal groups and assess clinical needs against established guidelines.
Ensure care levels are medically necessary and appropriate and engage potential high-risk claimants in care management protocols.
Coordinate with sales, account management, brokers, consultants, and group customers to support care management engagement with high-risk members.
Coordinate support for high-risk patients with family members, employers, and other supporters as appropriate.
Use medical and pharmacy claims reporting and risk-identification tools to assess risk.
Help maintain care management protocols for members receiving care outside Horizon BCBSNJ's service area and support appropriate use of special resources such as transplant centers and centers of excellence.
Assist underwriting in evaluating risks in existing and potential stop loss groups.
Work with pharmacy management to support efficient and appropriate specialty drug use and site-of-service delivery.
Evaluate care, solve problems, analyze variances, and participate in quality improvement activities to enhance member outcomes.
Respond to preferred partner inquiries for additional information on large claimants.
Serve as a resource to sales and account management teams on case management services and their interaction with stop loss management.
Identify and manage high-risk claimants within established stop loss customers.
Identify high-risk claimants within prospective stop loss customers.
Ensure appropriate and necessary care levels are followed for managed patients.
Ensure company functional areas and care delivery systems are engaged in high-risk claimant management.
Perform other duties as assigned by management.