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

Job Summary:

Responsibilities:

• Support all lines of business which includes Commercial and Government Programs.
• Collaborate with value based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable. Supports sales teams as assigned by region.
• Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable. Consult with/support case management to determine best course for members, assist with PG and address issues.
• Develops and maintains effective collaborative relationships with providers in assigned geographic areas. This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers.
• May provide input into provider credentialing, profiling and communication initiatives.
• Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management.
• Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix. Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region.
• Assists with assessment of network capabilities by region and collaborates with network management, contracting and value based teams in addressing network gaps.
• Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas.
• Participates in Committee activities as assigned.
• Assist with coverage across functional MD teams, as needed, including participation in calls for all areas.
• Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team.
• Works with legal and mandate team to support Horizon's compliance with the NJ Department of banking and insurance (DOBI).
• Backup chair for committees with internal and external stakeholders

Medical Policy and HPIRIT only:

• Performs medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed
• Support development and implementation of reimbursement policies
• Assist with coverage across functional MD teams as needed including participation in calls for all areas

Functional Competencies:

• Knowledge in the principles of Utilization Management, Case Management, Quality Management and accreditation/regulatory standards.
• Requires broad clinical knowledge and understanding of current health care issues and climate.
• Requires some knowledge of health insurance payer business including business operations.

Qualifications:

• Requires Board Certification in an American Board of Medicine recognized specialty.
• Requires current unrestricted MD or DO license to practice medicine.
• Requires 5-7 years Clinical Experience with managing data to identify key issues, developing recommendations and providing content/conclusions to executive management.
• Proficiency working with Tableau or similar software required.
• Proficiency also required working with a Windows based environment including MS Office products.
• Continuous Improvement Experience Preferred.

Specific to Medical Policy:

• Ability to review studies, understand evidence based medicine and support medical policy development.
• Ability to chair committees with internal and external stakeholders.

Additional licensing, certifications, registrations:

• Active Unrestricted MD or DO License Required; NJ License Required, No CMS Sanctions or sanctions by other regulatory agencies or boards.
• Must be board certified by a specialty recognized by the American Osteopathic Association or the American Board of Medical Specialties.

Knowledge, Skills and Abilities:

• Business Acumen: Identify key issues and opportunities, developing strategies and plans and have resolute decision making.
• Planning and Organizing: Leveraging resources, staying focused and effectively prioritizing key objectives.
• Building Strategic Working Relationships: Proactively tries to build effective working relationships; facilitates agreement; clarifies current situation; involving appropriate individuals within team and broader organization to achieve desired results
• Executive Presence: Advocates for the organization, inspiring confidence among peers regarding reliability and capability, inspiring senior leadership expectations on potential for outstanding outcomes and achievements.
• Meeting Leadership: Ensures a meeting serves its business objectives; facilitating agreement; develops others' and own ideas; closes discussions with clear summaries.
• Negotiation: Effectively exploring alternatives and positions to reach outcomes that gain the support and acceptance of all parties.
• Matrix Environment: Ability to function and work in a matrix environment which includes working on and at time leading cross functional teams.
• Conflict resolution: ability to identify conflict, determine its causes and negotiate mutually agreeable solutions.

Travel % (If Applicable):

• The position requires access to a car and the ability to travel for meetings with physicians, hospitals and ancillary providers as required.

Salary Range:

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.