NJM Insurance Group

Account Manager

• Acquires new business (Medicare Advantage Employer Group).
• Manages contract renewals (all markets for Dental) and ensures services are provided that will maximize the potential for account retention and initial member enrollment.
• Ensures proper installation of new accounts (Medicare Advantage Employer Group) as well as changes to existing accounts.
• Plans and negotiates terms and conditions of contracts with existing accounts.
• Directs the implementation process for new clients and/or employers.
• Sells additional lines of business to existing clients.
• Compares and evaluates various products to make appropriate recommendations based on client needs assessment.
• Modifies existing contracts that require term changes that may be outside of predetermined guidelines or standards.
• Develops and conducts workshops for clients/groups relative to enrollment, claim procedures, and health industry regulations.
• Weighs factors and outcomes to make binding financial, operational, and service-related decisions.
• Ensures that all accounts and brokers are promptly informed of relevant legislative and regulatory issues and their associated impact.
• Performs other duties as assigned by management.

Account Manager II

Analyst

• Accountable for occupancy planning and space management analysis and coordination
• Determine current and future space management and occupancy planning needs by conducting assessments, analyzing data and creating forecasts
• Prepare space analyses, develop strategies, and make recommendations that align with organizational goals
• Coordinate occupancy planning projects and scenario development, from programming and test fitting to implementation and presentation
• Support and manage customer expectations, conduct annual reviews and quarterly updates of space and occupancy planning work
• Facilitate meetings with relevant stakeholders, provide agendas, minutes, and project management fundamentals
• Report on and support program updates on a weekly, monthly, and quarterly basis, highlighting risks and opportunities
• Create and maintain templates and processes to standardize space requests, provide solutions, and build efficient space programs
• Partner with the real estate team on design management, review architectural plans, support with test fits, and support the move management team on large capital projects

Space & Occupancy Planning Analyst

Consultant

• Key member of account management team in its efforts to sell new business, inclusive of ancillary products
• Service, convert, and add additional lines of business to existing accounts and to convert accounts to managed care
• Create and facilitate client presentations and meetings, utilizing analysis of current client trends and plan design offerings
• Analyze data in order to recommend changes and cost saving designs incorporating medical management programs
• Responds timely and pro-actively to account or broker telephone inquiries by contacting the appropriate operating areas throughout the enterprise
• 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

Account Consultant II

• Handling all Utilization Management medical appeal cases
• Ensuring that timeliness guidelines are met and appeal handled in compliance with regulatory requirements
• Providing mentoring and clinical liaison support to appeals staff
• Assessing patient's clinical need against established guidelines and standards
• Evaluating the necessity, appropriateness and efficiency of medical services and procedures
• Performing review of medical records and preparing for review by Medical Director
• Investigating and resolving complicated appeals
• Coordinating with legal department as necessary
• Preparing and presenting appeals to Appeals Committee
• Conducting presentations of appeals process to internal customers
• Plans appropriate allocation of resources to provide quality patient care
• Documenting accurately and comprehensively
• Interacting and communicating with facilities, physicians and members/families
• Evaluating care by problem solving and analyzing variances
• Facilitating the external review process with the IURO and IRO
• Providing 24/7 on call appeal support as scheduled
• Actively participating in enterprise meetings as management's proxy

Appeals Resolution Analyst II – RN

Actuary

• Assist in developing premium rates for Individual and Small Group business.
• Support the preparation and submission of premium rate filings to state and federal regulators.
• Evaluate proposed benefit and cost‑sharing changes.
• Conduct pricing analyses and studies for Individual and Small Group segments.
• Assess the impact of proposed state and federal legislative changes.
• Perform Mental Health Parity compliance assessments.
• Provide support on additional actuarial projects as requested.
• Collaborate with internal teams and evaluate input received from cross‑departmental partners.
• Prepare and present reports with clear explanations and insights for managers and directors.
• Conduct experience studies and drill‑down analyses to identify key cost drivers and trends.
• Complete ad‑hoc modeling and analytical projects.

Actuarial Analyst II

• Provide business requirements, create action plans, and implement new and updated workflows
• Monitor various Association policies and procedures to ensure compliance
• Resolve common, complex, and escalated issues impacting provider and member claims
• Identify operational issues and initiate fixes to eliminate trends of claims adjudication
• Partner with IT on the implementation of systemic solutions
• Act as a liaison between internal divisions and the BCBSA
• Manage error reports from the BCBSA and initiate systematic solutions

National Programs Analyst

Clinical Operations

• Manages, analyzes and coordinates the daily activities of the unit to ensure departmental productive goals are met with regards to quality timeliness, accuracy and consistency of medical decisions.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies and procedures.
• Conducts continuous evaluation of workflows and seeks to improve processes that impact the department.
• Coordinates data collection, reviews compliance reporting and identifies opportunities for improvements.
• Identifies and implements cost saving/revenue generating opportunities.
• Serves as key liaison between Medical Directors, Management leadership, and staff.
• Also serves as a medical resource to members and providers, as well as non-clinical staff.
• Develops key performance indicators to evaluate level of service for internal and external customers.
• Acts as a subject matter expert for difficult and complex matters.
• Represents the Plan with external customers, providers and agencies.
• Represents the department on internal committees and participates in special projects.
• Assists Manager in coordinating regulatory, quality and accreditation activities.
• Performs other duties as assigned by management.
• Creates and champions an atmosphere within the team, which fosters open communication, teamwork, ownership, and a collaborative cross-departmental environment to implement, optimize and share continuous improvement processes.
• Manages, directs, and develops staff by providing feedback and coaching.
• Administers performance and salary reviews for staff.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practice methodology, professional standards, and internal policies and procedures.
• Assists in preparing and monitoring the budget to ensure administrative cost objectives are met.

Supervisor, Clinical Ops

• Provide timely and accurate responses to inquiries from the claim policy teams
• Prepares cases for Medical Director Review and or outside consultant review
• Responsible for processing pends for which the Medical Policy Inquiry Resolution team has authority
• Identifies opportunities for development of or revisions to Horizon Medical Policy based on case review
• Responsible for managing inventory assigned, documenting production in RMRS
• Stays abreast of all mandates, policy changes, workflow changes impacting outcomes
• Performs special projects as assigned by management

Medical Policy Analyst

Manager

• Responsible for performing care manager duties using established guidelines to ensure appropriate level of care for our members
• Coordinate the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care
• Evaluate the appropriateness and efficiency of all services designed to meet the member’s needs
• Coordinates and assists in implementation of care plan for members
• Act as subject matter expert for respective area for mentoring/ preceptor /training/remediation classes
• Conduct training and presentations in team meetings and facilitate ad-hoc training activities
• Participate in department workgroups to drive internal process changes and efficiencies
• Provide reports and feedback on mentees progress to assigned Supervisor as part of the orientation process; assist in the development of plan to identify opportunities for improvement
• Act as a subject matter expert and participate in user acceptance testing for medical management system
• Evaluates care management processes by problem solving, analyzing variances, and participating in the quality improvement program to enhance trained staff outcomes
• Participate in audit activities including IPRO, NCQA, or any other ad-hoc state audits.

Care Manager II, Specialty Programs

Business Analyst

• Investigate service related issues to identify root cause of issues;
• identify and communicate business needs assessments as necessary.
• May create forecasting tools using current technology/systems (Access, Excel, Monarch, etc.)
• May translate business requirements and assist IT with the development of technical specifications.
• Recommend solutions based on data analysis to increase business efficiency and/or improve existing processes.
• Participate in internal and external project workgroup(s) and presentations.
• Conduct User Acceptance Testing (UAT) for projects, implementations, system fixes and enhancements, etc.
• Prepare materials for internal and external audit activities; may review audit findings/reports for accuracy and completeness.
• Perform other relevant tasks as assigned by management.

Business Analyst II

• Monitor the financial performance of the large employer fully insured markets, including Midsize and Public
• Lead actuarial studies to refresh rating methodology and factors and manage the implementation of updates within the Stepwise rating engine
• Monitor and evaluate discount metrics for the large employer self-insured markets, identifying data quality issues and developing strategies to improve performance and accuracy
• Conduct pricing studies for new state mandates or other non-standard underwriting requests
• Oversee Mental Health Parity testing & compliance
• Forecast and manage performance guarantees for self-insured employers including the State Health Benefit Plan

Manager, Actuarial III

Business Intelligence Analyst

• Evaluate, write, and present utilization and cost containment reports
• Determine or agree upon deliverables with customer
• May need to be a liaison with IT/vendor and customer
• Perform appropriate analysis on data: forecasting, modeling, regression
• Mine data and perform appropriate analysis on data
• 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

• Acts as an individual’s primary advocate and care coordinator throughout the entire transplant journey, from initial evaluation and education to post-transplant recovery and long-term care
• Navigates complex medical, social, and financial barriers by coordinating with multiple providers and agencies
• Ensures appropriate care access and providing crucial support to individuals and their families during a challenging and emotional process
• Assesses patient's clinical need against established guidelines and/or standards
• 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
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided
• Documents accurately and comprehensively
• Interacts and communicates with multidisciplinary teams for continuity and efficiency
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
• Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques.

RN II, Care Manager – Ortho/Transplant

• Designs, develops and implements insurance products through state product filings
• Serves as subject matter expert for assigned line(s) of business
• Revising, creating or withdrawing NJM proprietary forms
• Answering line of business related questions from operations, underwriting, sales, marketing or other areas
• Acting as a resource to the other areas of Commercial Lines
• Researching information for various parties relating to competitive filings for forms, rules and rates
• Reviewing upcoming product revisions to ISO products, suggesting revisions to NJM products for enhancement

Product Development Analyst

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure.
• Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider.
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs.
• Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness.
• Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care.
• Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Encourages member participation and compliance in the case/disease management program efforts.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
• Serves as mentor/trainer to new RN's and other staff as needed
• Presents clinical cases during audits conducted by external review organizations.