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

What You'll Do

• 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 verify benefits and courses of treatment.

• Collect and collate information required to handle escalated phone/correspondence inquiries.

• Upon completion of inquiry investigation/resolution, initiate call back or correspondence to physicians/members to coordinate/verify case completion.

• Assist with on-boarding and training of newly hired Managed Care Coordinators I.

• Acts as liaison with providers, members and Care Managers.

• Perform other relevant tasks as assigned by management.

Utilization Management:

• Upon collection of clinical and non-clinical information, MCC can authorize services based upon scripts or algorithms used for pre-review screening. 

• Non Clinical staff is not responsible for conducting any UM review activities that require interpretation of clinical information.

• Performs initial screening of precertification requests from physicians/members received via incoming calls or correspondence using established scripts and workflows under the oversight of clinical /supervisory staff.

Case Management:

• Assists members with finding providers, resolving problems and answering questions regarding anything from how to obtain services to how to file an appeal.

• Makes outbound calls to in order to engage members in Case Management and to complete the necessary health assessment(s) (IHS/HRA, CNA/CMNA, MLTSS Elig Survey*).

• Distributes new case assignments to the Case Management Clinical Staff.

• Reviews medical, dental and vision claims and address gaps in member's preventative care.

• Educates members regarding preventive health activities and services.

• Assists members making appointments with their PCP, specialists, and/or transportation, etc. Process PCP, demographic changes and new ID cards as requested by members.

• Triage and distribute referrals from Member Services and incoming faxes from providers.

• Required to work one holiday shift per year

• Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards.

• Perform initial screening of determination letters, ensuring clarity and compliance before distribution.

• Make sound, timely decisions under the direction and supervision of a designated Supervisor.

• Review medical and administrative documentation for accuracy, grammar, and compliance with regulatory standards in both English and Spanish.

• Translate clinical and non-clinical documents between English and Spanish, ensuring precise medical terminology and context.

• Assist in the onboarding and training of new Managed Care Coordinators, providing guidance on language protocols and workflow processes.

What You Bring

Education/Experience:

• High School Diploma/GED required.

• 3-5 years customer service experience.

Additional licensing, certifications, registrations:

• Medical certification translator education  (Letter’s Team, Medically Certified Spanish Translator only).

Knowledge:

• Requires knowledge of medical terminology

• Requires Good Oral and Written Communication skills

• Requires ability to make sound decisions under the direction of Supervisor

• Prefer knowledge of contracts, enrollment, billing & claims coding/processing

• Prefer knowledge Managed Care principles

• Requires knowledge of clinical standards of care, and Star measures.

• Requires operational knowledge of health care delivery systems and health insurance industry.

• Requires appreciation for strategic planning.

• Requires knowledge of NCQA accreditation standards as well as state and federal laws applicable to health plan appeals and grievances. (Letters Team, Medically Certified Spanish Translator)

• Requires knowledge of CMS and state regulatory requirements. (Letters Team, Medically Certified Spanish Translator only)

Skills and Abilities:

• Prefer the ability to analyze and resolve problems with minimal supervision

• Prefer the ability to use a personal computer and applicable software and systems

• Team Player, Strong Analytical, Interpersonal Skills

Travel:

• May require some travel.

Why Horizon?

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:

​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.

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.