NJM Insurance Group

Business Intelligence Analyst

• Evaluate, write, and present utilization and cost containment reports
• Determine or agree upon deliverables with customer
• Liaison with IT/vendor and customer
• Perform analysis on data: forecasting, modeling, regression
• Mine data from appropriate system
• Present data and provide feedback to client and customer
• Develop relationships with subject matter experts (SME)
• Seek and adopt best practices in data reporting
• Perform other relevant tasks as assigned by Management

Data Reporting Analyst II

Call Center Representative

• Provide excellent service to customers through the resolution of basic customer inquiries received by phone or though written correspondence.
• Receive customer inquiries via phone, fax, mail, e-mail, etc.
• Probe for additional helpful information to effectively handle inquiry.
• Review computer systems and/or other reference materials to complete verification process.
• Initiate investigation process based on the nature of the inquiry (claim, member information, benefits, enrollment, appeals, etc.).
• Utilize available resources to resolve or redirect inquiries in accordance with departmental process.
• Document customer inquiries and actions taken to ensure appropriate follow up.
• Follow up on unresolved issues in a timely manner, escalating call trends to management.
• Deliver an excellent customer service experience while meeting quality and production standards.

Call Center Service Associate

Paralegal

• Provide litigation or transactional support under minimal supervision
• Research, monitor, update, and maintain current knowledge of developments in federal and state legislation, rules, regulations, enforcement actions and industry guidelines affecting the health insurance industry
• Organize, maintain and update departmental files
• Prepare legal documents for review, approval, and use by attorneys, as requested
• Analyze data and write reports as requested
• Provide administrative assistance as needed
• Perform factual investigation and research
• Assist in obtaining, organizing, analyzing and providing documents and information related to the litigation, investigation or subpoena
• Negotiate resolution of matters pursuant to authorized authority

Paralegal III

Learning and Development

• Partner with the Talent Development Team, HR Business Partners and other relevant stakeholders to identify performance gaps, design customized learning solutions, etc.
• Deliver formal and informal learning solutions, including presentations, workshops, training, and events via both in-person and virtual platforms
• Lead and facilitate large-scale events and programs
• Apply project management skills to organize resources for all phases of projects
• Develop evaluation tools to evaluate learning program outcomes and job-relatedness of training
• Conduct follow-up surveys and/or interviews with participants and managers to evaluate program impact
• Assist TD Management with sourcing and vendor selection
• Conduct evening new hire orientation on rare occasion, if required

Senior Talent Development Specialist

Analyst

• Supports the Health Services and Utilization Management functions
• Acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators
• Prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings
• Mentors more junior staff by responding to questions and sharing expertise
• Adheres to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows
• 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
• Manages correspondence of toll-free UM Appeal hotline and UM Appeal fax server
• Interacts with and supports Medical Directors
• Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors
• Prepares, documents and routes cases in appropriate system for clinical review
• Responsible for the comprehensive explanation of previous denials, the scope of coverage, and applied criteria
• Conducts and provides root cause analysis to avoid future appeal occurrences.

UM Appeals Analyst – MAC

Auditor

• Develops scope and work programs, assigns tasks, and ensures task accomplishment
• Identifies, develops and documents control issues
• Monitors ongoing performance and develops updates to recommendations
• Prepares formal written reports expressing opinions on internal control adequacy
• Builds strong relationships and gathers business risk information
• Oversees staff work to ensure quality and client satisfaction
• Reports progress of assigned audits and seeks input from management

Auditor III

Manager

• Perform RN duties for Primary Nurse population
• Outreach to high risk members for preventative care opportunities & screenings
• Develop member centric plan of care
• Assess member's clinical needs against established guidelines
• Coordinate delivery of high quality, cost-effective care
• Monitor member's medical care activities for appropriateness and effectiveness

RN II, Primary Nurse Care – Case Manager

• Responsible for performing RN duties using established guidelines to ensure appropriate level of care.
• Plans for the transition to the continuum of care.
• Assesses patient's clinical need against established guidelines.
• Coordinates and assists in implementation of plan for members.
• Monitors patient's medical care activities and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Serves as mentor/trainer to new RN's and other staff as needed.
• Represents clinical teams within committee meetings.

RN II, Case Manager

• Assess member’s clinical need against establish guidelines and/or standards for specialty population-based members.
• Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan.
• Partner with the member/family, physician, and all members of the healthcare team to ensure the member’s needs are met, internal and external to this organization.
• Advocate for the member among various sites to coordinate resource utilization.
• Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status.
• Ensure care for mandated non-compliant members through the monitoring of utilization.
• Document accurately and comprehensively based on the standards of practice and current organization policies.
• Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes.
• Monitor member’s care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness.
• Consult with internal stakeholders on complex cases and escalate as appropriate to internal physician resources.
• Complete other assigned functions as requested by management.

Care Manager I, Specialty Programs

• Monitor current day call queues and real-time performance metrics of the contact center
• Adjust and allocate resources to meet fluctuating demands and ensure that contact center goals are met
• Administer contingency action plans when deemed necessary
• Provide real-time updates and insights to management
• Manage WFM mailboxes and hotline to make timely skill changes and schedule updates to reflect accurate intraday projections
• Collaborate with team leaders to optimize staffing and scheduling
• Maintain accurate records of operational data and prepare daily reports
• Perform additional tasks and project-related work as business needs dictate

Real Time Scheduling Analyst

• Deliver accurate variance reports of various financial activities and demonstrate expert skills around analyzing and interpreting financials using statistical, financial, and operational data
• Explain and correct data variances and fluctuations
• Highlight issues and offer solutions to routine problems
• Prepare and review ad hoc analysis and benchmarking for assigned divisions or companies including analyzing financial and member data as well as compiling reports, graphs and presentations
• Lead complex analysis and detailed variances driving changes in accounts receivable
• Serves as a lead to the junior analysts and ensure the timely and accurate processing of monthly activities
• Verify certain the General Ledger balances to ensure complete, accurate and efficient financial reporting

Data Financial Reporting Analyst

Consultant

• Key member of account management team in its efforts to sell new business, inclusive of ancillary products
• Create and facilitate client presentations and meetings, utilizing anaylsis of current client trends and plan design offerings
• Analyze data to recommend changes and cost saving designs incorporating medical management programs
• Responds timely and proactively to account or broker telephone inquiries
• Must build strong internal and external relationships
• Resolves complex service issues, and answers product and benefits questions
• Assists in processing paperwork relating to the prospecting, enrollment, and/or termination of accounts
• Maintains the accuracy of the account profile and group administration through data updates
• Facilitates and coordinates the timely implementation of new groups and conversions
• Analyzes inter-departmental problems and makes recommendations for resolutions.
• Assists in the procurement of information from groups to complete and verify sale documentation.
• Responsible for reporting requests and confirming data accuracy.
• Performs other duties as assigned by management.

Account Consultant II

Pharmacist

• Responsible for all telephonic interaction with members, physician office staff, pharmacies and internal stakeholders for Pharmacy eligibility, coverage determination, and/or claim issues
• Engagement with physicians & pharmacists to conduct effective interventions through clinical therapeutic interchange to facilitate formulary compliance, optimize generic dispensing, and consistency with the current plan design
• Capture accurate and comprehensive clinical information for Prior Authorization requests from physicians and/or medical office staff to allow for clinical review and medical necessity determination
• Responsible for satisfying all departmental customer service quality metrics while ensuring that all DMAHS and DOBI required regulatory turnaround times are consistently satisfied
• Process complaints, appeals, grievances, executive inquiries and compliance related issues
• Responsible for identifying via interactions with members and providers, instances of potential fraud, waste, and abuse and resulting internal referrals that are necessary
• Provide recommendations to increase efficiency, accuracy and productivity in the department
• Process ad hoc request for information or reports from stakeholders
• Accountable for independent and group learnings to ensure understanding of pharmacy services procedures and workflows
• Assist in the day-to-day business functions of the pharmacy department as well as the Medication Therapy Management program
• Provide support to various clinical programs within the pharmacy department

Pharmacy Specialist I

Security Engineer

• Define, lead, and manage all aspects of the Third Party Risk Management (TPRM) Program.
• Identify, document, and communicate security risks and control deficiencies to business and IT stakeholders, driving awareness of emerging and relevant risks across Horizon BCBSNJ’s third-party landscape.
• Establish and maintain third-party privacy and security policies and standards, and oversee program effectiveness through measurement, governance, and continuous improvement.
• Serve as the primary information security risk interface to leadership teams, providing strategic guidance and insight on third-party and enterprise risk exposures.
• Direct and manage the Information Security Risk Management (ISRM) program, including team leadership, budget planning, resource allocation, and development of enterprise risk metrics and reporting.
• Ensure IT project risk assessments, application security reviews, and vendor risk assessments are integrated into the eGRC platform to support compliance with corporate information security policies and standards.
• Act as a trusted advisor to business stakeholders by maintaining ongoing awareness and alignment on identified and emerging risks.
• Partner with Internal Audit, Corporate Compliance, Office of General Counsel, and Risk Management to remediate identified issues, and track security-related findings within the eGRC system.
• Provide subject matter expertise and security risk consulting for third-party contracts (MSAs, BAAs, SOWs) and hosted services (SaaS, PaaS, IaaS) across all Strategic Sourcing engagements.
• Serve as the liaison to Enterprise Risk Management (ERM) for technology and cybersecurity risks, including collaboration on annual risk quantification for Horizon BCBSNJ’s Own Risk and Solvency Assessment (ORSA).
• Collaborate with the Director of Information Security and key stakeholders to enhance eGRC program procedures, controls, and the overall ISRM framework.
• Lead and manage security initiatives that address identified risks and business requirements, ensuring compliance with regulatory, legal, and industry best practices.

Senior Manager, Cybersecurity Risk

Human Resources

• Serve as a senior-level advisor to executives and business leaders, providing guidance on workforce planning, organizational strategy, team effectiveness, and leadership capability.
• Deeply understand the business’s goals, operating model, and challenges to develop integrated people solutions that accelerate performance.
• Use analytics, trend data, and insight-driven decision-making to proactively identify opportunities and mitigate risks.
• Lead organizational design efforts, including structure assessments, capability mapping, role clarity, and change impact analysis.
• Partner with business leaders to forecast talent needs and ensure the workforce is aligned to short- and long-term business plans.
• Drive the talent lifecycle, including succession planning, performance management, leadership pipeline development, and high-potential identification.
• Provide advanced guidance on complex employee relations matters, partnering with Legal and Employee Relations as needed.
• Collaborate with Centers of Excellence (COEs) such as Talent Acquisition, Total Rewards, Inclusion, Opportunity & Talent Development, and HR Operations to deliver seamless HR solutions.