Horizon Blue Cross Blue Shield of New Jersey

Appeals Analyst II - RN

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 3 hours ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

Responsible for handling Utilization Management medical appeal cases while ensuring compliance with regulatory requirements from agencies like NCQA and URAC. The role involves assessing clinical needs, resolving high-priority inquiries, and coordinating with the Medical Director and legal department.

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Complaint Res Analyst

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 12 hours ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $50100 - $67095 per year ⭐ 2-5 yrs exp 💼 Others

The role involves researching and investigating member and provider complaints to ensure timely and accurate resolution. It also requires compiling statistical reports and coordinating with internal departments to meet state compliance guidelines.

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RN II, -Oncology Case Manager-REMOTE

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 3 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 5-10 yrs exp 💼 Healthcare

Perform RN duties for the Primary Nurse population to ensure appropriate levels of care and develop member-centric plans. Coordinate high-quality, cost-effective care across the continuum and mentor new nursing staff.

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Sr. Analyst, Service

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 4 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $97800 - $133K per year ⭐ 5-10 yrs exp 💼 Others

Lead end-to-end process analysis and redesign to improve operational performance and customer experience. Partner with technology and business stakeholders to automate service delivery and ensure operational readiness for new system implementations.

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Specialist, Change Mgt & Business Readiness

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 4 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $109K - $149K per year ⭐ 5-10 yrs exp 💼 Others

Lead enterprise change management and adoption planning for service transformation initiatives across Operations. Ensure organizational readiness, stakeholder alignment, and sustainable adoption of business and technology changes.

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Supv, Out of Network Mandate

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 4 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $87300 - $119K per year ⭐ 5-10 yrs exp 💼 Others

Provides oversight for State and Federal Out of Network Mandate programs to ensure compliance with payment rules and consumer protection acts. Supervises a business team, managing productivity, training, and the implementation of operational standards.

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Hosp Contracting Spec II

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 5 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $87300 - $119K per year ⭐ 5-10 yrs exp 💼 Others

Lead and facilitate contract negotiations with hospitals, physicians, and ancillary providers across multiple lines of business. Collaborate with internal teams to implement payment models, ensure regulatory compliance, and execute network contracting strategies.

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Actuarial Analyst II

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 7 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Finance

The role focuses on Commercial Trend Forecasting, evaluating the financial impact of benefit changes and pricing studies. It involves analyzing legislative changes and conducting experience studies to identify cost drivers and utilization patterns.

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Pharmacy Specialist I

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 7 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $44600 - $59745 per year ⭐ 2-5 yrs exp 💼 Healthcare

Responsible for processing prior authorization requests and coordinating pharmacy services benefits through claim utilization analysis and clinical review. Acts as a primary point of contact for members, physicians, and pharmacies regarding eligibility, coverage determinations, and formulary compliance.

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RN II- CASE MGR.TRANSPLANT(REMOTE) HCC

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 10 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

The Transplant Case Manager acts as a primary advocate and coordinator for members throughout the transplant journey, from evaluation to long-term recovery. Responsibilities include managing clinical calls, performing triage, and coordinating with multidisciplinary teams to ensure cost-effective, high-quality care.

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Actuarial Analyst III

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 11 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $102K - $140K per year ⭐ 2-5 yrs exp 💼 Finance

The role supports premium rate development and pricing strategies for the Large Group market through financial impact studies and predictive modeling. It also ensures regulatory compliance, including Mental Health Parity reviews and state/federal rate filings.

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RN II, Primary Nurse Care (CASE MNGR.-REMOTE)

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 12 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

Responsible for managing a direct case management caseload, performing telephonic clinical triage, and conducting proactive outreach to high-risk members. The role involves developing individualized plans of care and coordinating with providers to improve health outcomes and facilitate transitions of care.

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RN II, Primary Nurse Care (Case Manager-REMOTE)

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 12 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

Perform RN duties for the Primary Nurse population to ensure appropriate levels of care and develop member-centric care plans. Coordinate with multidisciplinary teams and providers to manage transitions of care and engage high-risk members in preventative screenings.

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DSNP RN I, PCA/MDC

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 12 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $70500 - $94395 per year ⭐ 2-5 yrs exp 💼 Healthcare

Perform clinical assessments for PCA and MDC services to ensure appropriate levels of care and medical necessity. Coordinate high-quality, cost-effective care for members by collaborating with families, physicians, and multidisciplinary teams.

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Actuarial Analyst II

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 12 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Finance

Perform actuarial and data analytics for risk-adjusted business lines including ACA, Medicare Advantage, and Medicaid. Develop insights to guide risk adjustment strategy, financial projections, and pricing efforts.

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Account Manager III

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 19 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $92100 - $120K per year ⭐ 5-10 yrs exp 💼 Sales

The role focuses on the conservation of existing public market accounts and selling additional product lines to maximize retention. Responsibilities include negotiating contract terms, conducting client workshops, and ensuring stakeholders are informed of regulatory issues.

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Account Consultant II - National Accts

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 21 days ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $70500 - $94395 per year ⭐ 2-5 yrs exp 💼 Others

The Account Consultant II manages relationships with National 100+ accounts to maximize sales, retention, and business expansion. Key duties include facilitating client presentations, analyzing data for cost-saving designs, and resolving complex service issues.

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RN I

Horizon Blue Cross Blue Shield of New Jersey · Full Time · a month ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $70500 - $94395 per year ⭐ 2-5 yrs exp 💼 Healthcare

Responsible for assessing patient clinical needs against guidelines to ensure appropriate levels of care and length of stay. Coordinates high-quality, cost-effective care and manages transitions across the continuum of care for members.

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Digital Products Reporting Manager

Horizon Blue Cross Blue Shield of New Jersey · Full Time · a month ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $97800 - $133K per year ⭐ 5-10 yrs exp 💼 Others

Lead the reporting and analytics strategy for digital products to provide data-driven insights for senior management and external clients. Partner cross-functionally to measure the effectiveness of digital projects and optimize member experience goals.

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Med Dir., Prov Perf & Clin Transf

Horizon Blue Cross Blue Shield of New Jersey · Full Time · a month ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $214K - $297K per year ⭐ 10+ yrs exp 💼 Others

Responsible for designing and delivering provider education and performance management initiatives to improve patient experience, population health, and affordability. The role leads a team of clinical transformation specialists to drive value-based care goals and provider engagement.

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Mgr, Growth Operations

Horizon Blue Cross Blue Shield of New Jersey · Full Time · a month ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $123K - $167K per year ⭐ 5-10 yrs exp 💼 Marketing

Lead a growth operations team focused on pipeline management, BANT qualification, and CRM hygiene to scale the enterprise growth engine. Coordinate executive-level meeting generation and orchestrate complex enterprise deals across cross-functional teams.

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RN II, Primary Nurse Care

Horizon Blue Cross Blue Shield of New Jersey · Full Time · a month ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

Perform RN duties for the primary nurse population by developing member-centric plans of care and managing transitions in the continuum of care. Outreach to high-risk members to engage them in preventative care and serve as a mentor to new nursing staff.

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CPC Investigator

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 2 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $70500 - $94395 per year ⭐ 2-5 yrs exp 💼 Others

Perform audits and coding oversight of medical records to ensure compliance with CPT, HCPCS, and ICD-10 guidelines. Conduct low-level fraud investigations and manage pended claims to meet service level agreements for ASO and Blue Card accounts.

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Quality Mgmt Specialist

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 2 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $97800 - $133K per year ⭐ 5-10 yrs exp 💼 Others

Supports the Quality Management department through project planning, implementation, and the establishment of policies for Government and Commercial programs. Analyzes complex data to improve health plan quality ratings and member experience through CAHPS coaching and provider action plans.

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Business Process Engineer Sr. Process Design Specialist II

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 2 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $109K - $149K per year ⭐ 10+ yrs exp 💼 Software Development

Lead complex process improvement initiatives to reduce costs and complexity across the enterprise using Lean Six Sigma methodologies. Act as a strategic consultant to business leadership, developing business cases and mentoring staff toward Green and Black Belt certifications.

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RN II - Oncology Case Manager-REMOTE BASED

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 2 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $79100 - $105K per year ⭐ 2-5 yrs exp 💼 Healthcare

Responsible for performing RN duties to ensure appropriate levels of care and planning transitions within the continuum of care for oncology patients. This includes assessing clinical needs against guidelines, coordinating medical services, and serving as a mentor to new staff.

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Account Manager IV

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 3 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $125K - $151K per year ⭐ 10+ yrs exp 💼 Sales

The Account Manager is responsible for retaining existing labor market accounts and selling additional product lines while serving as the primary relationship manager. They coordinate across internal teams to ensure operational excellence, compliance, and the delivery of strategic support to fund trustees and administrators.

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National Programs Analyst

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 3 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $63000 - $84420 per year ⭐ 2-5 yrs exp 💼 Others

The National Programs Analyst coordinates the implementation of various Association initiatives and projects to support strategic and operational goals. This includes monitoring compliance, resolving claims issues, and collaborating with IT and other divisions.

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RN I

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 4 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $70500 - $94395 per year ⭐ 2-5 yrs exp 💼 Healthcare

This role involves performing RN duties using established guidelines to ensure appropriate levels of care and planning for care transitions, including assessing clinical needs against standards for inpatient stays. Responsibilities also cover evaluating medical services, coordinating care plans, monitoring services outside the network, and advocating for members across various care sites.

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RN Case Manager-ONCOLOGY (REMOTE)

Horizon Blue Cross Blue Shield of New Jersey · Full Time · 9 months ago

Horizon Blue Cross Blue Shield of New Jersey

🌎 United States 💵 $77900 - $104K per year ⭐ 2-5 yrs exp 💼 Healthcare

The RN Case Manager is responsible for assessing patients' clinical needs and coordinating care to ensure appropriate levels of care. This role includes monitoring services, advocating for members, and collaborating with multidisciplinary teams.

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