NJM Insurance Group

Manager

• Assesses patient's clinical need against established guidelines and/or standards to ensure appropriate level of care and length of stay
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided
• Coordinates and assists in implementation of plan for members
• Monitors and coordinates services rendered outside of the network and negotiates fees as appropriate
• Coordinates with patient, family, physician, hospital and other external customers regarding appropriateness of care from diagnosis to outcome
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines addressing the continuum of care
• Monitors patient's medical care activities and outcomes for appropriateness and effectiveness
• Advocates for the member/family to coordinate resource utilization and evaluate services provided
• Encourages member participation and compliance in case/disease management efforts
• Documents accurately and comprehensively based on standards of practice and organization policies
• Interacts and communicates with multidisciplinary teams telephonically and/or in person to ensure continuity and efficiency
• Understands fiscal accountability and its impact on resource utilization and self-care outcomes
• Evaluates care by problem solving, analyzing variances and participating in quality improvement programs
• Completes other assigned functions as requested by management

RN Case Manager

Consultant

• Support the Account Manager in maintaining group satisfaction and retention
• Provide an array of special services to new and existing accounts to maximize potential for new sales, retention, and expansion of business relationships
• Client-facing interactions for Mid-Size and 100+ segments critical to supporting account management and relationships
• Sell new business inclusive of ancillary products; service, convert, and add additional lines of business to existing accounts and convert accounts to managed care
• Open enrollment face-to-face client meetings
• Create and facilitate client presentations and meetings, utilizing analysis of current client trends and plan design offerings
• Analyze data to recommend changes and cost saving designs incorporating medical management programs
• Respond timely and pro-actively to account or broker telephone inquiries by contacting appropriate operating areas
• Build strong internal and external relationships
• Resolve complex service issues and answer product and benefits questions
• Assist in processing paperwork relating to prospecting, enrollment, and/or termination of accounts
• Maintain accuracy of account profile and group administration through data updates
• Facilitate and coordinate timely implementation of new groups and conversions
• Analyze inter-departmental problems and make recommendations for resolutions
• Assist in procurement of information from groups to complete and verify sale documentation
• Responsible for reporting requests and confirming data accuracy
• Perform other duties as assigned by management

Account Consultant II

Business Intelligence Analyst

• Under direct supervision, produce reports from various sources to provide the department/division with actionable information or business intelligence.
• Entry level position performing routine assignments.
• Assist in evaluating and writing utilization and cost containment reports.
• Mine data from appropriate system.
• Present data and provide feedback to manager or more senior analysts.
• Provide data entry in support of senior analysts.
• Utilize existing standardized reports.
• Seek and adopt best practices in data reporting.
• Perform other relevant tasks as assigned by Management.
• Some travel may be required.

Data Reporting Analyst I

Actuary

• Work with members of the Actuary/Analytics team to complete tasks related to existing initiatives
• Work with data sets to map structures and identify correlations between elements
• Identify and acquire additional data sets to enhance relevance and accuracy
• Perform actuarial tasks (reserve calculations, pricing analysis, experience analysis and studies, financial projections, other actuarial/financial calculations)
• Provide technical and analytical support for the actuarial department
• Perform work under general supervision

Actuary Intern

General Counsel

• The Assistant General Counsel is responsible for providing legal advice to the company with regard to various areas of assigned specialization. The incumbent has clear authority in specialized areas to act for the company. Also develops and maintains internal relationships and provides coordination with outside counsel when necessary. Responsibilities: Provides advice to management on legal issues concerning company business. Handles legal inquiries from within the company. Responds with legal opinion as appropriate. Prepares summaries of legal matters, as necessary. Serves on various internal committees as both participant and counsel, as required. Performs other duties as assigned by management. Litigation: Represents the company through all phases of judicial or administrative proceedings (including discovery, negotiations and arbitration) and in government investigations. Manages outside counsel and litigation budgets, serving as liaison between internal clients and outside counsel Receives and reviews lawsuits served on the company. Determines liability exposure and recommends whether to defend or settle. Negotiates and authorizes settlements, where appropriate. Prepares summaries of litigation and other legal matters, as necessary. Healthcare: Provides advice to management on legal issues relating to marketing requirements, claims, subscriber contracts, utilization management and provider credentialing and agreements. Monitors changes in the legal environment and assists business to come into compliance. Supports business units with product and process changes and liaise with regulatory agencies, as appropriate. Represents the company in matters before regulatory agencies. Corporate: Provides advice to management on legal issues relating to contracts, and general commercial or contractual negotiations. Reviews and negotiates contracts, leases and other agreements. Provides advice and guidance on issues of corporate governance, including Board Operations and related issues. Human Resources: Provides advice to management on legal issues relating to Labor and employee affairs. Receives and reviews employee related lawsuits and represents the company through all phases of judicial or administrative proceedings (including discovery, negotiations and arbitration). Determines liability exposure and recommends whether to defend or settle. Negotiates and authorizes settlements, where appropriate. Participates in labor negotiations process regarding representative Collective Bargaining Agreements.

Assistant General Counsel

Call Center Representative

Provide excellent service to customers through the resolution of basic customer inquiries received by phone or though written correspondence. Responsibilities: Receive customer inquiries via phone, fax, mail, e-mail, etc. If necessary, probe for additional helpful information (i.e. member ID, claim number, name, etc.) in order 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 quickly and efficiently resolve or redirect inquiries in accordance with prescribed departmental process. Accurately document customer inquiries and actions taken in accordance with departmental quality guidelines 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. Perform other relevant tasks as assigned by management.

Call Center Service Associate

Operations

The role is accountable for the oversight of operations supporting Braven Health. Successfully leads the execution of a portfolio of programs and projects that support Braven Health Medicare Advantage (MA) business. Enables the realization of Braven Health operational, quality, and financial goals. Partners with executive leadership to define, prioritize, plan, execute, and monitor Braven Health business. Accountable for the general oversight of operations supporting Braven Health. Oversees operational and financial performance. Develops and implements strategies to achieve performance and sustainability targets. Supports annual CMS bid submission and go-to-market implementation. Manages and optimizes administrative cost and budgets. Develops presentation material for governance forums. Reports directly to the Chief Executive Officer of Braven Health. Actively participates in the creation and execution of multi-year business plans and operating model. Develop business cases and maintain a project portfolio and roadmap for Braven Health. Identify and prioritize implementation and process improvement programs or projects that markedly move us towards operational excellence, repeatability, and scalability, including projects with a focus on improving member experience and retention. Conduct portfolio reviews with management team and ensure business owners are appropriately engaged and informed. Maintain effective communication with senior leadership (EVPs, SVPs), making them aware of portfolio status, critical risks, and issues. Foster collaboration between operational departments, leadership, and vendors to support improvements in operational and financial performance. Support annual product and go-to-market strategy, bid submission, and benefit implementation. Develop playbooks for a repeatable, consistent, and well-documented approach to industry-standard programs. Develop and maintain dashboards, scorecards, and tools that provide actionable insights into key performance indicator(s) for the Braven Health management team. Review externally facing Braven Health materials for accuracy and consistency. Identify opportunities for enhanced Braven Health education and training across operational teams and collaborate with Training Department to develop material. Use a data-driven approach to identify, escalate, and remediate critical risks and issues proactively. Conduct post-mortem exercises following project completion and monitor action plans to address challenges.

Director of Operations

Effectively direct customer service and claims processing operations on a departmental/product/program basis to meet organizational and customer needs and applicable goals
Leverage key internal and external relationships to access the information, products and resources necessary to successfully support the core activities of customer service and claims processing
Direct departmental operations to ensure timely, consistent achievement of prescribed goals including departmental performance targets, divisional quality & production standards, key enterprise priorities, Service Level Agreements (SLAs) and Performance Guarantees (PGs)
Hire, develop and retain high quality staff including coaching & mentoring, evaluating job performance, providing meaningful, timely feedback and appropriately addressing performance issues
Manage departmental budget, including all salary and non-salary costs, within established guidelines
Leverage knowledge, experience, data and tools to forecast, prepare for and respond to changes in inventory and/or greater business need/climate
Champion process/ workflow improvements within or across departments/divisions
Develop/influence successful partnerships, interfaces and communications with key enterprise departments to drive goal achievement
Capitalize on existing technology, optimizing system capabilities
Identify and elevate opportunities to incorporate new technology into processes and workflows
Lead high profile internal and/or external workgroups, presenting findings to appropriate leadership teams
Accountable for maintaining effective internal controls over the processes and transactions under areas of responsibility

Director, Service Operations

Software Engineer

• Horizon Blue Cross Blue Shield of New Jersey empowers members to achieve their best health and is New Jersey’s health solutions leader
• Responsible for designing, developing, and maintaining complex applications with interdependencies
• Translate business needs, requirements, and user stories into technical solutions while adhering to architectural standards
• Independently review complex business requirement documents/user stories and translate into technical specifications/user stories
• Develop, modify and maintain complex software products, including unit and system testing
• Enforce and mentor team on standardized code development, deployment, security protocols/standards and SDLC practices (Agile, Waterfall, Kanban)
• Analyze and troubleshoot complex problems and recommend remediation
• Perform production support, service requests, routine maintenance and off-hours deployment/checkout as required
• Provide status updates on development, testing and training deliverables and assist in monitoring project schedules and cost
• Lead cross-functional teams in technical capacity, design/code reviews, architecture discussions, and infrastructure reviews
• Provide guidance, training, and interact with external vendors and/or internal customers

Application Developer I

Analyst

Participates/presents case findings at the Leadership Appeals Workgroup hearings and mentors junior staff.
Appears before Leadership Appeals Workgroup to present cases, explain denials and address questions.
Contacts company areas to facilitate fact gathering and understand benefit contracts; may consult with outside attorneys or DOBI and may testify.
Authorizes administrative exceptions and conducts daily image queue review; conducts root cause analysis and recommends training to reduce appeals.
Works with Quality/Training to develop and deliver refresher training workshops; represents Complaints/Appeals function on work groups; assists new staff mentoring and reporting.