RN, Stop Loss High Level Claim

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

17h•$79,100 - $105,945

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 across the company. The role helps ensure care is coordinated throughout the care delivery system for high-risk members of groups with stop loss coverage underwritten by Horizon BCBSNJ. It uses established guidelines to assess appropriate levels of care and plan transitions of care. The RN works with care management and delivery functions, sales and account management, brokers, consultants, group customers, pharmacy management, underwriting, and external partners to identify and manage high-risk claimants. The position evaluates clinical needs and care, promotes care management engagement, uses medical and pharmacy claims reporting tools to assess risk, and supports appropriate care delivery, including specialty drug use and services outside Horizon BCBSNJ’s service area. The role also assists with evaluating risks in existing and prospective stop loss groups, responding to inquiries about large claimants, and improving member outcomes through analysis and participation in quality improvement. A minimum high school diploma or GED and an active New Jersey Registered Nurse license are required. The salary range is $79,100–$105,945. Horizon employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

Minimum high school diploma or GED.
Active New Jersey Registered Nurse license.
Minimum two years of clinical experience.
Minimum three years of experience in the health care delivery system or industry.
Minimum two years of health care payer experience.
Understanding of health and prescription insurance products, contracts, and benefits eligibility.
Understanding of health delivery systems and professionals.
Understanding of case, care, and 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 products (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 another applicable clinical specialty.
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.
Engage potential high-risk claimants in care management protocols.
Obtain support from sales and account management, brokers, consultants, and group customers to encourage care management engagement with high-risk members.
Coordinate support for high-risk patients, including with immediate and extended family members and employers, 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 facilitate use of appropriate special resources, such as transplant centers and centers of excellence.
Assist underwriting in evaluating risks in existing and prospective stop loss groups.
Work proactively 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 to enhance member outcomes.
Assist in responding to preferred partners’ inquiries for additional information on large claimants.
Serve as a resource to sales and account management teams on the interaction between case management services and stop loss management.
Identify high-risk claimants within established and prospective stop loss customers.
Manage high-risk claimants within established 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.