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.
About the Role
This 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.
What You'll Do
Clinical Assessment & Service Authorization
- Conduct comprehensive member assessments using established guidelines and assessment tools to determine appropriate levels of care and service needs.
- Evaluate the necessity, appropriateness, and effectiveness of healthcare services and procedures.
- Assess clinical needs and support authorization of services based on established standards and program requirements.
- Monitor healthcare utilization and member outcomes to ensure services remain appropriate and effective.
Care Coordination & Continuum of Care Management
- Coordinate and assist with the implementation of individualized care plans.
- Facilitate delivery of high-quality, cost-effective care across the continuum of care.
- Coordinate services among providers, healthcare facilities, family members, and community resources.
- Monitor and coordinate services delivered outside of the local area or network when appropriate.
- Support seamless transitions between healthcare settings and levels of care.
Member Advocacy & Engagement
- Advocate for members and families to ensure access to appropriate healthcare services and resources.
- Encourage member participation and compliance with care management and disease management programs.
- Help members navigate healthcare services and address barriers to care.
- Promote positive health outcomes through education, support, and ongoing engagement.
Collaboration & Communication
- Partner with physicians, hospitals, caregivers, and multidisciplinary teams to support coordinated care delivery.
- Build strong relationships with internal and external stakeholders to enhance the member experience.
- Communicate effectively to ensure continuity, quality, and efficiency of care.
- Participate in discussions and initiatives that improve coordination among care teams.
Quality Improvement & Documentation
- Maintain accurate, timely, and comprehensive documentation in accordance with professional standards and organizational requirements.
- Analyze care variances and identify opportunities to improve member outcomes.
- Participate in quality improvement initiatives and operational enhancement efforts.
- Apply sound clinical judgment and responsible resource utilization in decision-making.
Clinical Leadership & Professional Support
- Serve as a resource for peers and contribute knowledge-sharing activities.
- Participate in projects, committee work, and process improvement initiatives as needed.
- Support operational and system-related activities that improve care management processes.
What You Bring
Required Qualifications & Knowledge
Education & Experience
- High School Diploma or GED required.
- Minimum of two (2) years of clinical nursing experience.
- Minimum of two (2) years of healthcare payer experience.
Licensure & Certifications
- Active, unrestricted New Jersey Registered Nurse (RN) license or Compact RN license required.
Required Knowledge
- Knowledge of case management, care management, and disease management principles.
- Working knowledge of utilization management processes and practices.
- Knowledge of healthcare contracts and benefit eligibility requirements.
- Knowledge of hospital operations and healthcare reimbursement systems.
- Proficiency with Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.
- Familiarity with intranet and internet-based applications.
- Strong assessment, documentation, and care coordination skills.
Preferred Qualifications & Knowledge
Preferred Education
- Bachelor's degree preferred, or an equivalent combination of education and relevant experience.
Preferred Certifications
- Certified Case Manager (CCM) certification preferred for Clinical Advocate-related assignments.
Preferred Experience
- Experience working with PCA, MDC, SNP, Medicaid, Medicare, or managed care populations.
- Experience conducting field-based assessments.
- Experience supporting complex care coordination and community-based services.
Preferred Knowledge
- Understanding of member advocacy principles and whole-person care approaches.
- Knowledge of healthcare benefits, claims, and care coordination services.
- Experience with motivational interviewing techniques.
- Understanding of healthcare resource utilization and quality improvement practices.
Top Skills for Success
- Clinical Assessment & Service Evaluation
- Care Coordination & Case Management
- Member Advocacy & Relationship Building
- Critical Thinking & Problem Solving
- Communication & Active Listening
- Organization & Priority Management
- Collaboration & Teamwork
- Adaptability & Sound Clinical Judgment
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range
$70,500 - $94,395
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
Disclaimer
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.