RN, High Level Claim

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

This position is responsible for focusing stop loss risk management activities on the centralized stop loss team and coordinating risk oversight with care delivery related areas of the company. Assures care is coordinated across the company and throughout the care delivery system for high risk members of groups with stop loss coverage underwritten by the company. Uses established guidelines to ensure appropriate levels of care and to plan transitions of care.

• Works with care management and delivery functions of the company to identify potential high risk patients in new business and renewal groups, and to assess patient's clinical need against established guidelines, ensuring care levels are medically necessary and appropriate.

• Insures potential high risk claimants are engaged in care management protocols.

• Elicits support from sales and account management, brokers, consultants and group customers to insure care management engagement with high risk members.

• Provides special coordination for supporters of high risk patients, including immediate and extended family, employers, etc., as appropriate.

• Uses reporting and risk identification tools on medical and pharmacy claims to assess risk.

• Assists in assuring care management protocols are maintained for members receiving care outside Horizon BCBSNJ's service area, and that special resources (transplant centers, centers of excellence) outside of Horizon BCBSNJ are utilized where possible and appropriate to deliver care.

• Assists UW in evaluating risks in existing and potential stop loss groups.

• Works proactively with pharmacy management to insure efficient and appropriate specialty drug usage and site of service delivery.

• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

• Assists in responding to inquiries from preferred partners for additional information on large claimants.

• Acts as a resource to sales and account management teams in communicating case management services interaction with stop loss management.

• Performs other duties as may be assigned by management.

• Identify high risk claimants within established stop loss customers.

• Manage high risk claimants within established stop loss customers.

• Identify high risk claimants within prospective stop loss customers.

• Insure appropriate and necessary care levels are adhered to for managed patients.

• Insure functional areas of the company and care delivery systems are engaged in high risk claimant management.

Education/Experience:

• Minimum high school diploma or GED

• Prefer an associate's or bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school.

• Requires a minimum of two (2) years of clinical experience.

• Requires minimum of three (3) years of experience in the health care delivery system/industry.

• Requires minimum of two (2) years of experience with health care payer experience.

• Prefer advanced Excel, SQL or Tableau.

• Experience creating dashboards and reports.

Additional licensing, certifications, registrations:

• Requires an active NJ Registered Nurse License.

• Prefers pending or obtained certification in case management or other applicable clinical specialties.

Knowledge:

• Requires understanding of health and prescription insurance products, contracts and benefits eligibility

• Requires understanding of health delivery systems and professionals

• Requires understanding of case/care/disease management principles

• Understanding of stop loss reporting tools and requirements preferred.

• Understanding of risk mitigation, high claimant detection, engagement and management preferred.

• Requires strong inter-personal skills with a demonstrated ability to work across divisions and with external stakeholders

• Requires proficiency in the use of personal computers and in supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project) and Lotus Notes

Salary Range:

$76,800 - $102,795

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

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.