NJM Insurance Group

Business Operations

• Conducting data collection and analyses to support process improvement programs and projects
• Leading a variety of initiatives, ranging in complexity and scope, within business divisions
• Drafting and reviewing project deliverables and analyses such as value-stream mapping and statistical analyses
• Supervising business process analysts in the project team environment
• Developing business cases using ROI models in direct relationship to strategic corporate goals
• Interacting with subject matter experts to develop solutions that improve process performance
• Planning and participating in BPI organization building and activities to help promote the BPI brand

Senior Business Process Engineer, Process Design Specialist

Account Manager

• Manages contract renewals and ensures services are provided that will maximize the potential for account retention and initial member enrollment
• Majority of account management and sales are via phone call and emails.
• Ensures proper installation of new accounts as well as changes to existing accounts.
• Plans and negotiates terms and conditions of contracts with existing accounts.
• 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.
• Ensures that all accounts are promptly informed of relevant legislative and regulatory issues and their associated impact.
• Performs other duties as assigned by management.

Compliance

• Maintain knowledge of all relevant legislative and regulatory health plan requirements and monitor information sources for changes in regulatory compliance program requirements for Horizon’s LOBs
• Analyze information and determine what is informational versus change affecting organizational processes
• Review, interpret, summarize and communicate new and revised requirements to the business unit personnel using multiple distribution methods
• Provide plain language compliance guidance and direction to operationalize regulatory compliance requirements and support implementation of changes stemming from new or revised State and Federal requirements
• Oversee compliance with new, revised, and pending regulatory requirements through the Requirements Database, and collect and evaluate evidence of compliance submissions from business unit personnel
• Support and actively participate in annual team functions including monitoring, ongoing risk assessment, audit readiness activities, external audit coordination, executing the compliance workplan, and other divisional priorities related to risk mitigation
• Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics for the group
• Independently investigate areas of non-compliance, and act on matters by designing and coordinating internal investigations and resulting corrective action plans with all departments
• Identify potential non-compliance vulnerabilities and make practical business recommendations to correct non-compliance or improve insufficient processes
• Monitor business units’ self-monitoring results to ensure that current procedures satisfy regulatory requirements and are sufficient to detect future instances of non-compliance
• Assist with the development of compliance policies, control processes, self-monitoring, and self-auditing tools that promote maintaining compliant business processes
• Develop and update Standard Operating Policies and Procedures (SOP) for review processes and compliance
• Educate stakeholders on these SOPs
• Develop collaborative relationships with regulators
• Monitor compliance related commitments made to regulatory agencies governing Horizon’s LOBs, and review and maintain submissions, reports, and filings to regulators

Regulatory Compliance Associate

Software Engineer

• Lead, mentor, and develop Desktop Engineering and Messaging teams, including managers, engineers, and specialists.
• Establish clear performance expectations, career development plans, and succession strategies.
• Define and execute the enterprise strategy for endpoint computing, mobility, virtual desktops, and messaging platforms, ensuring alignment with Horizon’s technology roadmap and business priorities.
• Oversee day-to-day operations for endpoint and messaging services to ensure high availability, performance, and strong user satisfaction, while meeting defined SLAs and operational metrics.
• Partner with Cybersecurity to ensure all endpoints and messaging systems comply with security standards, regulatory requirements, retention policies, and legal hold obligations.
• Drive modernization initiatives such as cloud-based device management, collaboration enhancements, automation, and AI/Copilot adoption to improve productivity and operational efficiency.
• Provide accountability for enterprise messaging services, including email, calendaring, collaboration tools, and related integrations, ensuring stability, scalability, and compliance.
• Collaborate closely with Service Desk, Infrastructure, Networking, Identity, Asset Management, and vendor partners to ensure seamless end-user service delivery.
• Manage budgets, licensing, contracts, and vendor relationships related to desktop, endpoint, and messaging technologies.
• Ensure cost-effective solutions and accurate forecasting.
• Establish and enforce standards for endpoint builds, messaging configurations, security controls, documentation, and operational processes.
• Develop and maintain business continuity plans and disaster recovery strategies to ensure endpoint and messaging services can withstand disruptions.
• Provide executive-level oversight during major incidents, outages, migrations, or security events impacting endpoints or messaging platforms, ensuring timely resolution and root cause remediation.
• Track performance metrics, analyze data, and provide regular reports to leadership on performance and accomplishments.
• Ensure adherence to IT policies, industry regulations, and legal requirements related to data protection and privacy.

Senior Manager, Desktop Engineering, Messaging

Medical Director

• Support all lines of business which includes Commercial and Government Programs
• Collaborate with value-based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable
• Supports sales teams as assigned by region
• Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable
• Consult with/support case management to determine best course for members, assist with PG and address issues
• Develops and maintains effective collaborative relationships with providers in assigned geographic areas
• This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers
• May provide input into provider credentialing, profiling and communication initiatives
• Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management
• Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix
• Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region
• Assists with assessment of network capabilities by region and collaborates with network management, contracting and value-based teams in addressing network gaps
• Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas
• Participates in Committee activities as assigned
• Assist with coverage across functional MD teams, as needed, including participation in calls for all areas
• Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team
• Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI)
• Backup chair for committees with internal and external stakeholders
• Performs medical reviews for the Clinical Inquiries Team (CIT) and support special investigations unit as needed
• Support development and implementation of reimbursement policies
• Assist with coverage across functional MD teams as needed including participation in calls for all areas

Business Analyst

• Assist in the development of intelligent insights from analysis of both quantitative and qualitative data, testing basic hypotheses, running exploratory analysis and identifying trends in support of business strategies and goals.
• Assists in translating results/findings into clear and concise presentations for management and develop plans for corrective action.
• Assist in the development and enhancement of department KPI dashboards, analytics and reports to monitor performance to create a comprehensive view of the business.
• Assist in collaborating with cross-functional business teams and Data Engineers to fully understand the meaning, business rules and structure of required data and ensure alignment and consistency of data to support the end-to-end journey.
• Partner with the department Business Process Unit to identify, plan and prioritize source system improvements that facilitate data analytics.
• Assist in expanding understanding/knowledge of business processes and competitive environments.
• Scan the market to understand key trends impacting markets, customers, products, services and operational processes.
• Assist in complying with Data Governance standards and guidelines for data definition, quality, accuracy, completeness, availability and security to encourage data integrity and conformance.

Insurance Product Management Analyst

Actuary

• Support forecast development and financial projections, reserves and analytics for the Medicaid lines of business.
• Assess the impact of proposed state and federal legislative changes.
• Perform experience analysis for Medicaid products, including medical cost, utilization, and trend components.
• Monitor emerging experience and identify drivers of variance from expected results.
• Prepare actuarial exhibits, summaries, and documentation for internal leadership and external stakeholders.
• Provide support for additional actuarial projects as requested.
• Assist with Medicaid quarterly financial reporting, certifications, and responses to state inquiries.
• Support analysis related to benefit changes, policy updates, and regulatory requirements.
• Evaluate the financial impact of program changes, quality initiatives, and value‑based arrangements.
• Ensure analyses align with CMS and state Medicaid guidelines.
• Develop, maintain, and enhance actuarial models used for Medicaid analysis.
• Validate data sources and ensure accuracy, consistency, and reasonableness of results.
• Apply actuarial judgment in selecting assumptions and methodologies under guidance from senior staff.
• Partner with Finance, Network, Clinical, and Operations teams to support Medicaid initiatives.
• Communicate analytical results clearly to non‑actuarial stakeholders.
• Respond to ad-hoc data requests and analytic questions related to Medicaid performance.

Actuarial Analyst II

• Support all lines of business which includes Commercial and Government Programs.
• Collaborate with value-based teams, Behavioral Health and Pharmacy; supports accounts and activities for cross functional areas by region, where applicable.
• Supports sales teams as assigned by region.
• Guides, supports and consults with nurse reviewers on pre-authorization, concurrent and retrospective review issues, post-service reviews, pre-determinations and decisions, where applicable.
• Consult with/support case management to determine best course for members, assist with PG and address issues.
• Develops and maintains effective collaborative relationships with providers in assigned geographic areas.
• This includes on site or virtual review of performance and coaching activities with physicians, hospitals and ancillary providers.
• May provide input into provider credentialing, profiling and communication initiatives.
• Responsible for data analysis on case management and utilization, identify issues and escalate as necessary to senior management.
• Interprets and analyzes available utilization, cost and quality reports and develops steps to address variances to target performance matrix.
• Collaborates on documentation of monthly reporting address performance, issues and activities for assigned region.
• Assists with assessment of network capabilities by region and collaborates with network management, contracting and value-based teams in addressing network gaps.
• Creates/participates in internal or external educational activities for other members of the team/stakeholders across regional/functional areas.
• Participates in Committee activities as assigned.
• Assist with coverage across functional MD teams, as needed, including participation in calls for all areas.
• Support medical policy development process, review medical and pharmacy policies and provide feedback regarding utilization to the development team.
• Works with legal and mandate team to support Horizon’s compliance with the NJ Department of banking and insurance (DOBI).

Sales

• This position is accountable for providing leadership and strategic management of teams of account management and new business sales professionals and Account Consultants.
• Responsible for driving a culture of execution with a focus on obtaining new quality business, the conservation of existing accounts, increasing the profitability of the book of business, and the growth of additional lines of business to existing customers.
• Develops and monitors goals for staff and provides ongoing feedback and coaching.
• Conducts performance reviews on an annual basis and actively manages performance issues.
• Directs the employment activities of the office that include staffing, development, and training.
• Ensures staff meets all licensing requirements and comprehends and complies with sales and account management best practices, professional standards, internal policies, and procedures.
• Determines departmental budget and conducts ongoing expense management.
• Develops and maintains relationships with accounts to enhance credibility and reinforce presence in the marketplace.
• Approves and implements changes and enhancements to product design, pricing, and sales strategy, in collaboration with Underwriting.
• Conducts annual sales forecasting, determination of market potential, and the preparation of annual budgets.

Director, Sales

Manager

• Assesses patient's clinical need against established guidelines and/or standards
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures
• 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
• Interacts and communicates with multidisciplinary teams

RN II – Oncology Case Manager

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
• 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
• Assists in preparing and monitoring the budget to ensure administrative cost objectives are met

Supervisor, Clinical Ops

Call Center Representative

• Provide real time management support for the call center teams
• Monitor, adjust and troubleshoot issues and activities of call centers on a real time basis
• Identify trends, identify root cause analysis and make recommendations utilizing call center best practices to ensure efficiencies
• Revise and adjust schedules for call centers based upon planned and historical occurrences
• Coordinate telephonic changes with Telecom and business management
• Provide reports to management on the daily, weekly, monthly, quarterly, and yearly findings
• Perform related tasks as assigned by management

Call Center Analyst I

• 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

Business Intelligence Analyst

• Assist in the development of intelligent insights from analysis of both quantitative and qualitative data
• Testing basic hypotheses, running exploratory analysis and identifying trends in support of business strategies and goals
• Translating results/findings into clear and concise presentations for management
• Develop plans for corrective action
• Enhance department KPI dashboards, analytics and reports to monitor performance
• Collaborate with cross-functional business teams and Data Engineers
• Partner with the department Business Process Unit to identify, plan and prioritize source system improvements
• Scan the market to understand key trends impacting markets, customers, products, services and operational processes
• Assist in complying with Data Governance standards and guidelines for data integrity

Claims Business Insights Analyst, Associate

Underwriter

• Verify accuracy and completeness of information necessary to process transactions
• Process transactions such as mid-term changes and issue new business and renewal policies
• Act on any specific renewal activities or instructions
• Review incoming policy specification inquiries and/or Renewal Questionnaires and recognize changes that need to be addressed and/or referred
• Manage all work assignments and plan for date sensitive activities in advance of taking PTO
• Handle certificate requests from customers in a timely fashion

Senior Business Process Engineer, Process Design Specialist

Account Manager

Regulatory Compliance Associate

Senior Manager, Desktop Engineering, Messaging

Medical Director

Insurance Product Management Analyst

Actuarial Analyst II

Medical Director

Director, Sales

RN II – Oncology Case Manager

Supervisor, Clinical Ops

Call Center Analyst I

Care Manager I, Specialty Programs

Claims Business Insights Analyst, Associate

Commercial Lines Underwriting Technician