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 providing day-to-day guidance, support and medical leadership for utilization management activities and decisions within the Behavioral Health function. This position is responsible for supporting the Medical Director-Behavioral Health in all aspects of utilization management. Analyzes data from a variety of sources to identify trends and or issues. Participates on various internal or external committees as assigned.

What You'll Do

Responsibilities:

• Provides medical expertise based on extensive knowledge of health care delivery systems, utilization and reimbursement methods, and treatment protocols for the Behavioral Health function.​
• Supports, guides and consults with BH Clinician reviewers on pre-authorization, concurrent and retrospective review issues or decisions.
• Supports, guides and consults with BH Clinician reviewers on case management issues or decisions.
• Supports, guides and consults with BH Clinician reviewers on medical necessity and medical appropriateness issues or decisions.
• Participates in the development, planning and management of complex cases and communicates management plan to the provider.
• Guides staff in the interpretation of medical policy. Assists in Medical policy and technology assessments and recommendations.
• Assists or consults on appeal review process.
• May provide input to provider credentialing, profiling and communication initiatives and network development.
• Analyzes data from a variety of sources to identify trends and/or issues.
• Participates on various internal or external committees as assigned.

What You Bring

Education/Experience:

• Requires board certification as an MD or DO with a current unrestricted license to practice medicine in one of the primary care specialties.
• Requires a minimum of five years clinical experience and three or more years medical management in a managed care setting.

Addendum for Child Psychiatrist

• Completion of approved residency in Psychiatry.
• Completion of accredited Child and Adolescent Psychiatry Fellowship.
• Child Psychology Board eligible by start date.

Special Licenses and Certifications:

• Government Programs - Active Unrestricted NJ MD or DO License Required; HCM.
• Active Unrestricted NJ MD or DO License Required.

Knowledge:

• Requires knowledge in the principles and procedures of Utilization Management, the URAC Health UM Standards and peer review.
• Requires excellent understanding of the principles and concepts of managed care.
• Requires knowledge of the health insurance payor business, including operations.
• Requires broad clinical knowledge and understanding of current health care issues.

Skills and Abilities:

• Requires broad clinical skills to understand medical issues and to discuss them with physicians.
• Requires the ability to exercise independent judgement in making medical necessity decisions.
• Requires the ability to interpret and apply medical policy and provide guidance to others.
• Requires strong communication skills.
• Requires analytical skills to evaluate data from various sources to identify trends and issues.

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:

$214,100 - $297,885

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:

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.