NJM Insurance Group

Risk

• Assesses patient's clinical need against established guidelines to ensure appropriate level of care
• 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
• Documents accurately and comprehensively based on standards of practice
• Interacts and communicates with multidisciplinary teams to ensure continuity of care
• Evaluates care by problem solving and participating in quality improvement programs
• Outreaches to members identified by Horizon as needing Clinical Advocate services
• Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families

RN II – High Risk Maternity & NICU Case Manager

Auditor

• Responsible for the quality review of claims to enhance the clinical, network, and case management services offered.
• Conduct file audits for all areas of clinical operations.
• Perform audits on claims and correspondence to determine accuracy and completeness.
• Schedule and coordinate all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
• Create and maintain medical consultant calendar to ensure daily coverage.
• Maintain records and prepare reports on quality audit results.
• Evaluate quality audit procedures including quality scorecards and audit point sheets.
• Respond to internal/external clinical customer complaints/appeals.
• Conduct offsite meetings to educate physicians on process improvement initiatives.
• Participate in audits based on operations requests.
• Verify all professional licenses for RN & medical consulting staff.
• Analyze, prepare, and distribute quarterly audit outcomes.
• Document CMS-CAPs results in SharePoint database.
• Conduct ad hoc file audits when new business practices are set in place.

Clinical Quality Auditor II – RN/SW

• Provide resolution to identified overpayments utilizing various methods i.e., written correspondence, outbound call, or adjustment to a claim.
• Research/adjust claims (i.e., Coordination of Benefits, no-fault, claim policy, authorizations, and referrals) in accordance with Plan contract provisions and all other governing policies and/or procedures.
• Research and resolve Accounts Receivable (AR) issues to include the disposition of Cash Receipts in Universal Payment System (UPS).
• Ensure accurate and timely resolution of service requests and activities is provided in accordance with the customer's health benefit coverage and company policy.
• Anticipate and resolve potential issues and follow through on commitments made to the customers.
• Coordinate with other areas within and outside of Service to address customers' inquiries regarding claim payment, benefits and/or appeals.
• Follow up on unresolved issues via outbound calls, emails or faxes.
• Share knowledge and information willingly with team members to achieve team, division, and Enterprise goals while enhancing service quality.
• Submit provider file updates as appropriate.
• Receive inbound telephone calls as they relate to recovery efforts.
• Perform other related tasks as assigned by management.

Process Auditor I

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.
• 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

Product Manager

• The Digital Product Manager will act as the primary business owner for multiple digital assets within Horizon, responsible for partnering in the development and implementation of the Digital Strategy vision.
• Develops and delivers digital products and services for assigned portfolio.
• Incumbent works cross-functionally to define the strategic roadmap, and with the team, carries that through to the product backlog.
• Prioritizes Horizon's investment in building capabilities to support and enable business and technology strategies.
• Ensures the economic return on these investments, and monitors the effectiveness and efficiency of the delivery of the capability building initiatives.
• Manage the strategic product roadmap.
• Build and prioritize a product backlog.
• Supports execution against the approved product roadmap and prioritizes the product backlog of features.
• Collaborates with Product Owners / Business Analysts to ensure Themes/Epics are being broken down into workable user stories ready to be worked on by developers.
• Own the management and continual development of the assigned portfolio of digital assets.
• Take the role of 'Product Manager' in Agile projects by approving new features/functionality, Subject Matter Expert (SME) for their respective product(s).
• Approves work controls of the team; ensuring that the work item is agreed to and the acceptance criteria are met.
• Build strong strategic relationships with Executive level business leaders.
• Engages the other business stakeholders, acting as a point of contact for cross-functional collaboration.
• Works with Marketing, Product, and Design teams to understand user experience and business pain points / hot spots.
• Leads and guides business partners in the analysis, selection and implementation of technology and services.
• Provides product capability assessment and direction to business partners in IT to help support technology decision process.
• Drives product capability decisions that help increase efficiency and improve user experience.
• Aligns with the Strategy and Architecture team to insure that decisions are consistent with the Architecture and Strategy roadmap.