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

Responsible for the oversight of team dedicated to researching and responding to escalated complaints received from regulatory offices, e.g. Department of Banking and Insurance, Offices of the Attorney General, Legislative offices as well as those that are received by Horizon executives and the office of Public Affairs. Manager is responsible for ensuring mandated and internal goals for timeliness, quality and production are achieved.

What You'll Do

• Direct staff to ensure overall member satisfaction while handling sensitive and escalated complaint issues within mandated resolution timeframes. Develop and monitor goals for staff and provide ongoing feedback and coaching both internally and outside of the department, where appropriate.
• Develop/Update enterprise wide training material relative to Complaint/Appeal handling.
• Prepare and Monitor Enterprise Corrective Action Plan for Complaint/Appeal timeliness
• Identify opportunities and best practices and implement process improvements (i.e., root cause analysis, technological assessments, etc.) to optimize performance and administrative cost. These improvements can be internal or may involve other departments within the organization.
• Responsible for timely adherence with compliance, training and reporting requirements as determined by internal and external regulatory/accreditation agencies and policies.
• Develop, administer and monitor Service Level Agreements (SLAs) with appropriate business partners to ensure timely and accurate responses to escalated complaints.
• Review and maintain Enterprise Administrative policies and Charters that govern Inquiries, Complaints and Appeals.
• Develop and/or maintain business partnerships and represent the department and the enterprise to Regulatory agencies
• Perform other related tasks as assigned or required.

What You Bring

Experience/Education:

• HS Diploma or GED required. Bachelors Degree preferred.
• Minimum of five (5) years of managerial experience required.
• Experience managing in a fast paced, high volume, transaction-driven environment necessary.
• Successful track record managing inventory as well as other service operations metrics and reports, with process improvement experience preferred.

Knowledge:

• Proficient in service operations; managing inbound customer service call centers claims, call center, membership and billing processes.
• Knowledge of industry trends, legislation, and execution of project management
• Knowledge of State and Federal Mandates, regulations, Health Care Reform
• Knowledge of NCQA requirements and policies
• Knowledge of healthcare or insurance policy and/or operations preferred.
• Requires knowledge of DOL regulations as they relate to member appeals

Skills and Abilities:

• Strong leadership, decision-making, strategic problem solving, negotiations, analytical, excellent verbal & written, and interpersonal skills.
• Strong and effective communication skills, both verbal and written.
• Strong analytical skills; uses to validate plans and approaches
• Ability to understand and interpret consumer and group health plan contracts
• A commitment to excellence and to making a difference; results driven, improvement focused, and action oriented self-starter who can handle various responsibilities simultaneously and proactively and continually look for a better way of doing things.

Travel:

• Some travel may be required.

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:

$109,600 - $149,625

​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.