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 accountable for the assessment and case management of Dual Special Needs members using established guidelines to ensure appropriate level of care as well as developing a member centric plan of care.
What You'll Do
Member Assessment & Care Planning
- Assess members' clinical, functional, and psychosocial needs using established clinical guidelines and care management standards.
- Evaluate the medical necessity, appropriateness, and effectiveness of services provided.
- Develop, coordinate, and support implementation of individualized, member-centered care plans.
- Identify healthcare needs, barriers to care, and opportunities to improve outcomes.
Care Coordination & Member Advocacy
- Coordinate care and services with members, families, physicians, hospitals, community organizations, and other healthcare providers.
- Ensure seamless care coordination across the continuum of care, from diagnosis through treatment and ongoing support.
- Advocate for members and families to ensure access to appropriate services, programs, and community resources.
- Facilitate resource utilization and service coordination across multiple care settings.
Case Management & Monitoring
- Provide field-based and telephonic case management services for -SNP members.
- Monitor healthcare services and member outcomes regardless of the site of care.
- Track member progress and evaluate the effectiveness of interventions and care plans.
- Identify changes in member conditions and coordinate timely interventions as needed.
Quality, Documentation & Compliance
- Maintain accurate, thorough, and timely documentation in accordance with professional standards and organizational policies.
- Ensure adherence to care management guidelines, regulatory requirements, and quality standards.
- Support delivery of high-quality, cost-effective care guided by evidence-based clinical practice standards.
- Promote quality outcomes through ongoing assessment, monitoring, and follow-up.
What You Bring
Required Qualifications & Knowledge
Education & Experience
- High School Diploma or GED required.
- Minimum of three (3) years of broad clinical experience.
- Minimum of three (3) years of experience in home care, discharge planning, case management, or a related healthcare setting.
- Minimum of three (3) years of experience working within the healthcare delivery system.
- Active, unrestricted New Jersey license as one of the following:
- Registered Nurse (RN)
- Licensed Practical Nurse (LPN)
- Social Worker (SW)
- Certified Social Worker (CSW)
Required Knowledge
- Strong knowledge of case management standards and best practices.
- Strong understanding of managed care concepts and healthcare delivery systems.
- Knowledge of HEDIS measures and quality improvement principles.
- Strong knowledge of medical terminology.
- Understanding of care coordination, resource management, and member advocacy.
- Knowledge of community resources and support services available to vulnerable populations.
Preferred Qualifications & Knowledge
Education & Experience
- Bachelor's degree in Nursing, Social Work, Healthcare, Behavioral Health, or a related field.
- Experience working with elderly, frail, disabled, or complex-needs populations.
- Experience supporting Medicare, Medicaid, Dual Eligible, or Special Needs Plan (SNP) populations.
- Experience conducting field-based care management and home visits.
Preferred Knowledge
- Familiarity with dual eligibility programs and government-sponsored healthcare plans.
- Knowledge of population health management and chronic condition management.
- Understanding of social determinants of health and their impact on healthcare outcomes.
- Experience coordinating care across medical, behavioral health, and community-based services.
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
$63,000 - $84,420
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.