RN, Data Analyst

Horizon Connect @ Wall BCBSNJ

. Focus stop loss risk management activities on the centralized stop loss team and coordinate risk oversight with care delivery areas .

Posted 10/22/2026full-timeRemote • United StatesMid-LevelSenior💰 $79,100 - $105,945 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in stop loss risk management and care coordination for high-risk patients, leveraging clinical experience and understanding of health care delivery systems. Proficient in using reporting tools and managing care protocols to ensure optimal patient outcomes.

Highest-signal resume keywords

Stop Loss Risk ManagementClinical ExperienceHealth Care Payer ExperienceCase Management CertificationAdvanced Excel

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical AssessmentCare CoordinationRisk IdentificationQuality ImprovementDashboard CreationData AnalysisCare Management ProtocolsHealth Insurance KnowledgeDisease Management PrinciplesPharmacy Management

Soft Skills

Interpersonal SkillsCollaborationStakeholder EngagementCommunication

Tools & Technologies

SQLTableauMS Office SuiteLotus Notes

Certifications & Qualifications

NJ Registered Nurse LicenseCase Management Certification

Industry Keywords

Health Care Delivery SystemHigh Risk PatientsCare ManagementPharmacy ManagementHealth Insurance Products

Tech Stack

Tools & technologies

SQLTableau

About the role

Key responsibilities & impact

Focus stop loss risk management activities on the centralized stop loss team and coordinate risk oversight with care delivery areas
Assure care is coordinated across the company and throughout the care delivery system for high risk members
Use established guidelines to ensure appropriate levels of care and plan transitions of care
Work with care management and delivery functions to identify potential high risk patients in new business and renewal groups
Assess patients' clinical needs against established guidelines
Ensure high risk claimants are engaged in care management protocols
Elicit support from sales, account management, brokers, consultants and group customers
Coordinate support for high risk patients with families, employers and other appropriate parties
Use reporting and risk identification tools on medical and pharmacy claims to assess risk
Maintain care management protocols for members receiving care outside the service area
Assist in evaluating risks in existing and potential stop loss groups
Coordinate with pharmacy management regarding specialty drug usage and site of service delivery
Evaluate care, analyze variances and participate in quality improvement programs
Respond to preferred partner inquiries regarding large claimants
Act as a resource to sales and account management teams regarding case management services and stop loss management
Identify and manage high risk claimants within established and prospective stop loss customers
Ensure appropriate care levels and engagement across company functions and care delivery systems
Perform other duties assigned by management

Requirements

What you’ll need

Minimum high school diploma or GED
Prefer an Associate's or Bachelor's degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school
Requires a minimum of two (2) years of clinical experience
Requires minimum of three (3) years of experience in the health care delivery system/industry
Requires minimum of two (2) years of experience with health care payer experience
Requires an active NJ Registered Nurse License
Prefers pending or obtained certification in case management or other applicable clinical specialties
Prefer advanced Excel, SQL or Tableau
Experience creating dashboards and reports
Requires understanding of health and prescription insurance products, contracts and benefits eligibility
Requires understanding of health delivery systems and professionals
Requires understanding of case/care/disease management principles
Requires strong inter-personal skills with a demonstrated ability to work across divisions and with external stakeholders
Requires proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint, MS Project) and Lotus Notes

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement