NJM Insurance Group

Auditor

• Analyze incoming subrogation demands by identifying key elements to determine whether the demand is reasonable, or if changes are recommended
• Provide documentation to the requested Adjuster for support in negotiations with the adverse carrier
• Review incoming Premier Car Care Estimates for possible estimating irregularities with high complexity
• Examine the Images and Audit report to make appropriate changes based on guidelines and best practices
• Monitor your queue for changes requested to ensure timely follow up by shop
• Track changes that are not accepted or modified incorrectly
• Properly document and report these issues to Quality Service Supervisor
• Identify and analyze Total Loss estimates to determine that they are in line with Company guidelines
• Communicate any issues with the shop and ensure necessary changes are made

Auto Damage Appraisal Auditor

Analyst

• Develop content to support enterprise strategic initiatives
• Conduct research and perform qualitative and quantitative analyses
• Synthesize analyses into clear recommendations
• Present complex topics to team leads comfortably and effectively
• Develop charts or pages within a deck
• Develop strong, cross-functional working relationships.
• Manage successful knowledge transfer to business units to ensure proper implementation.

Strategic Initiatives Analyst I

Compliance

• Responsible for the identification and communication of new, revised, and pending federal and state laws, regulations, and standards relevant to a Horizon Lines of Business (LOB)
• Administers and coordinates the functions associated with compliance and regulatory guidelines related to each market
• Develop and maintain standard operating policies and procedures, compliance reporting and dashboards
• Support and actively participate in annual team functions including monitoring, ongoing risk assessment, audit readiness activities, and external audit coordination
• Independently investigate areas of non-compliance and design and coordinate internal investigations and resulting corrective action plans
• Gather relevant data and Key Performance Indicators for compliance reports and dashboards, and prepare reports based on established reporting metrics

Regulatory Compliance Associate

Bilingual

• Supports the Clinical Operations functions and acts as a liaison between members, physicians, and service coordinators.
• Performs review of service requests for completeness and collects non-clinical data.
• Initiates call backs/correspondence to coordinate and verify benefits/treatment.
• Assists members with finding providers and resolving problems regarding services.
• Makes outbound calls to engage members in Case Management.
• Reviews medical, dental, and vision claims.

Managed Care Coordinator II, Bilingual – Spanish Speaking

Systems Engineer

• Lead the process of identifying and recommending coding solutions for enterprise projects and complex benefit coding problems
• Validate and approve business requirements
• Understand Mandates, Product Development coding grids and BRDs and interpret what is required for benefit updates
• Create and deliver work estimates to Project Managers
• Document project one-pager dashboards with schedule, budget, blockers, progress
• Assist with claims testing scenarios
• Document standard operating procedures

Business Systems Analyst IV, Benefits Coding

• Accountable for the oversight, implementation, and execution of the Medicaid regulatory compliance program
• Owns Medicaid compliance program design, monitoring, audit readiness, issue management, and remediation
• Leads compliance risk assessments and audit planning
• Oversees intake, investigation, and resolution of potential non-compliance
• Partners with Legal, Government Affairs, and business leaders on regulatory interpretation
• Reports material compliance risks to senior leadership and the Chief Compliance Officer
• Leads and develops compliance staff
• Primary regulatory contact for Medicaid matters with regulatory agencies

Medicaid Compliance Officer

• This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators.
• The incumbent prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings.
• Incumbent will mentor more junior staff by responding to questions and sharing expertise.
• 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.
• Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives via incoming calls or correspondence based on workflows.
• Interacts with and supports Medical Directors.
• Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors.
• Prepare, document and route cases in appropriate system for clinical review.
• Responsible for the comprehensive explanation of previous denials, the scope of coverage, applied criteria, and how the case was handled.
• Responsible for addressing questions posed by the appellant or committee and administrative support of completing the appeals process.
• Conducts and provides root cause analysis to avoid future appeal occurrences.
• Works with supervisor to develop and deliver refresher training to business teams on proper appeal referral, handling, and MAC case preparation.
• Assists in the development of junior staff through mentoring, coaching and assisting them in the proper handling of appeal cases.
• Assist with running and validating reports for the team.
• Perform other relevant tasks as assigned by Management.

UM Appeals Analyst – MAC

Account Manager

• Manage contract renewals, including negotiating terms and approving contract modifications outside standard guidelines
• Assess client needs and recommend appropriate products
• Serve as the day-to-day account lead, maintaining consultative relationships
• Represent Horizon at trustee meetings, board meetings, and client requested forums
• Proactively manage client expectations and escalate issues as appropriate
• Partner with Data & Reporting teams to deliver client specific reporting and performance insights
• Experience with ASO groups both Full Administration and Shared Administration
• Coordinate internally with various teams to resolve complex issues
• Develop and conduct client and group workshops related to enrollment, claims procedures, and healthcare industry regulations
• Analyze relevant factors and outcomes for decision making
• Ensure accounts and brokers are informed of applicable legislative and regulatory updates
• Perform additional duties as assigned by management

Account Manager – IV

Manager

• 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
• Acts as subject matter expert for respective area for projects
• Advocates for the member/family among various sites to coordinate resource utilization

Telephonic Case Manager, RN II

• 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
• Coordinates with patient, family, physician, hospital and other external customers
• Advocates for the member/family among various sites to coordinate resource utilization
• Documents accurately and comprehensively based on standards of practice
• Collaborates with multidisciplinary teams for continuity and efficiency
• Evaluates care by problem solving and analyzing variances.