Care Manager I, Specialty Programs (Burlington/Mercer Counties)

Job Summary 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. Responsibilities Assess member’s clinical need against established 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. Qualifications Requires a license as an RN, or a bachelor’s degree in social work, health, or behavioral science. Graduate‑level degree in Social Work or Health and Behavioral Science preferred. Requires a minimum of three (3) years’ experience serving members with special needs. Knowledge Strong knowledge of the standards of practice for case managers. Strong knowledge of managed care principles. Strong knowledge of specialty population, as applicable. Skills & Abilities Strong organizational skills. Strong oral and written communication skills. Good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.). Good problem‑solving and conflict‑resolution skills. Requires a car with a valid New Jersey state license and insurance for certain positions. Compensation Salary Range: $70,500 - $94,395 Compensation decisions are dependent on the circumstances of each case. Benefits Comprehensive health benefits (Medical/Dental/Vision) Retirement Plans Generous PTO Incentive Plans Wellness Programs Paid Volunteer Time Off Tuition Reimbursement Eligibility Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. Equal Opportunity / Affiliation Statement Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr 100 Horizon Healthcare Services, Inc