Horizon Connect @ Wall BCBSNJ

Risk

• Lead coordination of analytics and process functions within the Enterprise Risk Adjustment department
• Gather and organize status of operational activities across the risk adjustment department
• Participate in or lead internal or external project workgroups and presentations
• Provide regular reporting on operations and analytics functions, with actionable insights for department and enterprise leadership
• Author presentation materials and conduct research for external and leadership audiences
• Request analytics and reporting to support risk adjustment alignment decisions
• Collaborate with business unit and divisional leaders to define problems, design solutions, and manage implementation related to product development, network design, and pricing practices
• Present risk adjustment materials and status updates to Horizon leadership
• Escalate departmental issues and track them to resolution
• Support management through ad hoc reporting and special projects
• Manage, develop, and train staff; develop and monitor goals; conduct annual performance reviews; administer staff salaries

Manager, Risk Adjustment Operations

• Develop and lead risk adjustment vendor strategy aligned to enterprise goals
• Identify vendor needs, source and evaluate partners, and define success measures
• Negotiate contracts and own day-to-day vendor relationships
• Lead RFPs, vendor selection, implementation, and offboarding
• Manage onboarding and wind-down activities including data retention and destruction
• Ensure effective transition and integration of vendor services
• Design and maintain KPI frameworks for vendors and internal operations
• Develop models and reporting to measure financial impact and operational outcomes
• Analyze performance trends and identify improvement opportunities
• Audit internal and vendor reporting for accuracy and completeness
• Ensure data integrity and adherence to measurement standards
• Support compliance and internal control requirements
• Monitor vendor spend, billing, and budget performance
• Develop forecasts and provide financial insights to leadership
• Advise on budget risks and mitigation strategies
• Review and reconcile vendor invoices to ensure accurate and timely payment
• Partner with enterprise leaders to define targets and corrective actions
• Present insights and recommendations to executive stakeholders
• Mentor and guide analytics and reporting teams

Manager, Risk Adjustment Vendor & Performance Management

• Perform care management duties targeting high-risk members within commercially risk-adjusted populations
• Assess high-risk members' health status annually and engage members in preventative care opportunities and screenings
• Facilitate navigation of high-risk members to appropriate care settings and annual wellness visits
• Coordinate transitions from RAM RN to care management RN
• Encourage member participation and compliance in case/disease management programs
• Collaborate with RAM Business Analysts and Manager to engage at-risk members
• Deploy clinical engagement strategies using RAM insights, member outreach calls, and retail pharmacy information
• Develop ad-hoc clinical outreach strategies and interpret RAM analytical reports
• Develop and expand member outreach initiatives, including potential physician or pharmacy visits
• Assess clinical needs against established guidelines and develop, coordinate, and assist with individualized plans of care
• Evaluate medical service necessity, appropriateness, and efficiency
• Coordinate with members, families, physicians, hospitals, and external customers across the continuum of care
• Monitor medical care activities and outcomes for appropriateness and effectiveness
• Advocate for members and families across care sites
• Document accurately and comprehensively according to standards and policies
• Evaluate care, analyze variances, and participate in quality improvement programs
• Mentor/train new RNs and other staff as needed
• Perform other duties assigned by management

RN II, Commercial Risk Adjustment

Clinician

• Perform behavioral health duties using established guidelines to ensure appropriate level of care and plan transitions to the continuum of care
• Assess patients' behavioral health clinical needs against established guidelines and standards for medically appropriate inpatient care and length of stay
• Evaluate the necessity, appropriateness and efficiency of behavioral health medical services and procedures
• Coordinate and assist in implementing member care plans
• Monitor and coordinate out-of-network and out-of-area services, including fee negotiations as appropriate
• Coordinate with patients, families, physicians, hospitals and external customers regarding appropriateness of care from diagnosis to outcome
• Coordinate high-quality, cost-effective care across the continuum using clinical practice guidelines
• Monitor behavioral health care activities and outcomes for appropriateness and effectiveness
• Advocate for members and families across care sites to coordinate resource utilization and evaluate services
• Encourage member participation and compliance in behavioral health case/disease management programs
• Document accurately and comprehensively according to standards of practice and organizational policies
• Communicate with multidisciplinary teams telephonically and/or in person to promote continuity and efficiency
• Evaluate care, solve problems, analyze variances and participate in quality improvement programs
• Complete other assigned functions as requested by management

Auditor

• Lead on-site audits of hospital billing and coding practices and desk audits
• Develop, profile, and track institutional audit trends
• Design audit protocols and special projects
• Perform and finalize per diem, bill verification, DRG Validation/utilization review audits, and credit balance audits
• Provide guidance and instruction to stakeholders on ICD-10-CM, ICD-10-PCS, DRG assignment, payment, and auditing
• Identify and present billing discrepancies found during audits
• Coordinate referral of improper claim payments through appropriate channels
• Identify error trends related to medical records, billing documentation, and provider contract stipulations
• Compile statistics and audit information for accounts, regulatory agencies, and internal requesters
• Review and update audit processes with the manager to keep pace with clinical data review innovations and cost-containment initiatives
• Train new staff on department and audit procedures
• Perform other special assignments requested by the manager
• Comply with laws, regulations, and policies applicable to organizational business units

Inpatient Hospital Auditor II

Analyst

• Manage the end-to-end appeals process, including receiving appeals, entering data into the medical management system, facilitating external vendor review, and completing cases timely.
• Speak with providers and members about the appeal process and appeal status.
• Answer and triage the appeal Hotline phone queue.
• Collaborate with internal and external vendors to process appeals according to NCQA, DOBI, State, and other regulatory standards.
• Update authorizations based on appeal outcomes and ensure claims are effectuated timely.
• Collaborate with internal customers to ensure notification of appeal outcomes.
• Perform testing and projects to meet departmental goals.
• Resolve basic clinical appeals for Government Programs under supervision while meeting timeliness and accuracy standards.

Appeals Resolution Analyst

Procurement

• Assist in the selection, development, negotiation, and execution of contracts covering commercial items or services.
• Gather and present utilization and spend information for sourcing category strategies.
• Integrate procurement processes and policies into regular business practice with internal clients.
• Assist with accurate completion of WorkDay processes and compliance with procurement policies.
• Support RF(x)-related activities with Strategic Sourcing staff, internal clients, and external suppliers.
• Procure assigned goods and services via eProcurement tools and evaluate products and services for overall value.
• Obtain quotes, conduct cost analysis, and participate in price and term/condition negotiations.
• Provide first-tier problem resolution for quality, delivery, Accounts Payable, outstanding items, damaged goods, and incorrect shipments.
• Assist Strategic Sourcing staff with special projects.
• Generate queries and reports from Strategic Sourcing systems for internal customers.

Sourcing Analyst

• Support the Enterprise Business and Technology Solutions Vendor Management Office and Vendor Forensic Analysis function
• Assist management in overseeing the vendor portfolio with a focus on strategic vendor governance and risk management across EBTS service providers
• Collaborate with stakeholders to monitor vendor performance, service delivery, issues, contract changes, and overall vendor effectiveness
• Provide input into vendor selection and management activities related to technology and professional services contracts
• Review vendor performance, utilization, and business outcomes
• Support vendor performance management through scorecards, monitoring tools, and periodic assessments
• Review service level agreements and performance guarantees with Vendor Relationship Owners and contract owners for 80 to 100 vendors
• Assist with vendor reviews, audit activities, documentation collection, and analysis
• Review, develop, and recommend process improvements
• Review contract budget variances and vendor spend trends; guide corrective actions and escalate issues requiring remediation
• Serve as a liaison for contractual issues, vendor disputes, and vendor governance matters
• Support enterprise vendor purchase order processing, vendor reporting, data analysis, and related operational activities
• Assist with data collection, documentation, and maintenance of standard operating procedures and repository materials

Senior Analyst, Vendor Management

• Handle all Utilization Management medical appeal cases.
• Ensure timeliness guidelines and regulatory requirements are met, including NCQA, URAC, and NJ/Federal regulations.
• Provide mentoring and clinical liaison support to appeals staff.
• Assess patients’ clinical needs against established guidelines and standards for inpatient level of care and length of stay.
• Evaluate the necessity, appropriateness, and efficiency of medical services and procedures provided by inpatient facilities.
• Review medical records and prepare records for Medical Director review as appropriate.
• Investigate and resolve complicated appeals, coordinating with the legal department as necessary, including appeals concerning pre-existing conditions.
• Investigate and resolve high-priority cases involving DOBI and Executive inquiries.
• Prepare and present appeals to the Appeals Committee, coordinating with independent URO.
• Present the appeals process to internal customers and assist Delegate and Vendor Oversight with vendor procedures.
• Plan resource allocation to provide quality patient care cost-effectively.
• Document accurately and comprehensively according to standards of practice and organizational policies.
• Communicate with facilities, physicians, members, and families telephonically or on site to support continuity and efficiency of care.
• Evaluate care by problem-solving, analyzing variances, and participating in quality improvement programs.
• Facilitate the external review process with IURO and IRO.
• Provide scheduled 24/7 on-call appeal support.
• Participate in enterprise meetings as management’s proxy when necessary.
• Work specified weekends and holidays as required by regulatory and accrediting standards.
• Perform special projects as assigned by management.

Appeals Resolution Analyst II – RN

Manager

• Perform care coordination duties using established guidelines to ensure appropriate level of care and plan transitions to the continuum of care for specialty populations.
• Implement interventions to ensure efficient utilization of benefits.
• Assess members’ clinical needs against established guidelines and standards.
• Implement high-quality, cost-effective care based on customized population models and clinical practice guidelines.
• Partner with members/families, physicians, and healthcare teams to meet member needs.
• Advocate for members across sites and coordinate resource utilization.
• Set priorities, plan, organize, and implement goal-directed interventions supporting self-care outcomes and transition to independent status.
• Ensure care for mandated non-compliant members through utilization monitoring.
• Document accurately and comprehensively according to practice standards and organization policies.
• Evaluate care, solve problems, analyze variances, and participate in quality improvement.
• Monitor care activities and outcomes for appropriateness and effectiveness.
• Consult internal stakeholders on complex cases and escalate to internal physician resources as appropriate.
• Complete other assigned functions as requested by management.

Care Manager I, Specialty Programs

Investigator

• Gather, analyze, and interpret documentation to conduct investigations
• Support investigators in researching and resolving fraudulent activity
• Analyze exposure, provider, and claims data using relevant systems and software
• Manage Special Investigations Unit pended claims to meet SLAs and service standards for ASO accounts and Blue Card requirements
• Ensure timely, accurate, and efficient resolution of pended claims in NASCO and the BPM tool
• Serve as primary contact for fraud claim inquiries and referrals
• Research, document, and track issues in Blue Card admin and/or BPM tools; forward issues and track resolution
• Conduct investigative activities on less complex case reviews, including analyzing coding and preparing, documenting, and assembling evidence for potential prosecution and civil litigation
• Collect and submit information for claim suspension entries via ClearQuest tickets and update claim suspensions
• Create and maintain UCSW/NCompass alerts and handling instructions; share active claim suspension listings for financial reporting and claim savings tracking
• Investigate Fraud Hotline calls, including member and provider outreach, medical-record requests, and claim review
• Follow established procedures and research across multiple systems and tools; share systems and tool knowledge with Investigative and/or PPR staff
• Analyze and review confidential and highly sensitive investigative materials concerning employees, subscribers, providers, and groups
• Assist with claims and/or UCSW/NCompass inventory reports, daily aging reports, and process automation reports
• Collect, collate, analyze, and interpret data and documents for investigations and subpoena fulfillment

Investigator I

Care Coordinator

• Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
• Prepare, document and route cases in appropriate system for clinical review.
• Initiates call backs and correspondence to members and providers to coordinate and clarify benefits and case completion.
• Reviews professional medical/claim policy related issues or claims in pending status.
• Acts as liaison with providers, members and Care Managers.
• Authorizes services based upon scripts or algorithms used for pre-review screening under clinical staff oversight.
• Handles initial screening for pre-certification requests based on scripts and workflows.
• Assists members with finding providers, resolving problems, answering questions, filing appeals, and obtaining services.
• Makes outbound calls to engage members in Case Management and complete necessary health assessments.
• Educates members regarding preventive health activities and services.
• Assists members with appointments, transportation, PCP and demographic changes, and new ID cards.
• Triages and distributes referrals and provider faxes.
• Reviews medical, dental and vision claims and addresses gaps in members' preventive care.
• Performs other relevant tasks as assigned by Management.

Managed Care Coordinator – I

• Perform review of service requests for completeness, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
• Prepare, document and route cases in the appropriate system for clinical review.
• Initiate callbacks and correspondence to members and providers to coordinate and clarify benefits and case completion.
• Review professional medical/claim policy-related issues or claims in pending status.
• Act as liaison with providers, members, Care Managers, Physicians, Delegates, Operational Business members and Member Service Coordinators.
• Authorize services based on scripts or algorithms used for pre-review screening, under clinical staff oversight.
• Handle initial screening for pre-certification requests via incoming calls or correspondence based on scripts and workflows.
• Assist members with finding providers, resolving problems, answering questions, filing appeals, and obtaining services.
• Make outbound calls to engage members in Case Management and complete health assessments.
• Educate members regarding preventive health activities and services.
• Assist members with appointments, transportation, PCP and demographic changes, and new ID cards.
• Triage and distribute referrals and provider faxes.
• Review medical, dental and vision claims and address gaps in preventive care.
• Review medical and administrative documentation for accuracy, grammar and regulatory compliance.
• Perform initial screening of determination letters before distribution.
• Make sound, timely decisions under Supervisor direction and perform other assigned tasks.

Managed Care Coordinator

Customer Support

• Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business
• Review medical policies and determine appropriate claim processing or clinical review process decisions
• Coordinate clinical review and appeal processes, including preparing cases for clinical review and requesting additional information from members and providers
• Review clinical determinations and initiate appropriate claim adjustments and service request closeout, including drafting manual letters
• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements
• Review and update Coordination of Benefit (COB) files and submit provider file updates as necessary
• Identify technical issues and submit them to the appropriate area for resolution
• Handle relevant incoming telephone inquiries as needed
• Perform other tasks as assigned by management