This position supports the Clinical Operations functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators Responsibilities Performs review of service requests for completeness of information, collection and transfer of non clinical data, and acquisition of structured clinical data from physicians/pa

The Risk Adjustment Data Analyst II will contribute to the end to end encounter process workflow and supports program activities around risk adjustment data submissions to federal & state agencies on a timely basis, ensuring the accuracy and compliance of the data submitted. The analyst will also be responsible for timely completion of projects, including timeline develop

This Specialist will support the Provider Account Manager with establishing and fostering collaborative, trusting provider relationships to drive improved provider satisfaction and performance. This position will help drive execution of key support deliverables, be a data SME, and ensure project work plans are executed resulting with high quality deliverables. Responsible

Job Profile Summary This position is accountable for providing support to the field based Care Managers (RN II and Care Specialist III). In addition, Clinical Care Associates serve as the first point of contact for our members looking for service and/or provider information as well as members or providers requesting authorizations and denials of services. This position co

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and com

The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, diseas

Responsible for all workforce functions including budgeting, capacity planning, forecasting, scheduling and real time monitoring. Own and manage creation of leveryday tactical workload forecasting while continuously improving forecasting accuracy taking into consideration new hire classes, meetings, coaching product releases and key disruptions. Provide strategic insight

The position is responsible for leading a specific clinical care team in a hands on manner to provide exceptional service to the customer and contain medical claims cost. This is accomplished through active involvement and leading of the day to day operations of a clinical care team and ensuring staff is consistent with Horizon's policies and procedures and are compliant

This position is responsible for supporting the Quality Management department with improvements through project planning, development and implementation, and the establishment of policies and procedures pertaining to regulations in both Government Programs and Commercial business. Responsibilities Develop project initiatives, process and performance measures for Quality M

This position is responsible for providing leadership and oversight of the overall clinical and non clinical operations. Assists Director in establishing, interpreting and implementing new and existing company policies and procedures. The manager is also responsible for the adherence and maintenance of the regulatory agency requirements for DOBI, NCQA, DOL, DMHAS and CMS

This position is accountable for providing support to the field based Care Managers (RN II and Care Specialist III). In addition, Clinical Care Associates serve as the first point of contact for our members looking for service and/or provider information as well as members or providers requesting authorizations and denials of services. This position coordinates and secure

This position is responsible for ensuring documented operational compliance to state, federal and accreditation standards in Utilization Management and/or Case Management. Is the subject matter expert in UM and/or CM for DOBI, IPRO, CMS and NCQA. Maintain library of policies and audit documentation. Track and trend operational deficiencies identified by internal and exter

This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Responsibilities Assesses patient's clinical need against established guidelines and/or standards to ensure that the l

The Medical Director is a medical spokesperson for Horizon Blue Cross Blue Shield with the provider network across NJ. The Medical Director will be accountable for providing leadership, direction and daily support for their assigned region of NJ and assigned providers; the scope of activities include, but are not limited to, utilization management, care management, diseas

This field based position is responsible for performing assessments for PCA and MDC services using established guidelines and assessments to ensure appropriate level of care and services are authorized. Responsibilities Assesses patient's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to members