Director, Care & Case Management - Government Programs

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

Job Description:

• Provide leadership for Complex Case and Care Management team with oversight in areas such as opportunity analysis and evaluation, vendor due diligence and selection, contract development and maintenance, new program implementation, and ongoing operations.
• Develop and manage Complex Case and Disease Management improvement programs that reach measurable qualitative and financial metrics.
• Directs and facilitates Care Coordination in a multitude of care settings.
• Facilitates and ensures effective, efficient quality care and member safety.
• Coordinate and facilitate behavioral health services and ensure quality care delivery
• Participate in an integrated fashion with other areas of Clinical activity; specifically, inpatient and other utilization management areas and chronic care management to ensure strong process for referrals.
• Maintain a quality management system that ensures processes are meeting customer requirements including the establishment, tracking, trending, and reporting of case management operational metrics and clinical outcomes.
• Directs department by providing strategy and related goals to day-to-day managers, ensuring overall client satisfaction and appropriate level of service delivery.
• Ensures staff meets all regulatory requirements and comprehends and complies with best practices, professional standards, internal policies, and procedures.

Education/Experience:

• High School Diploma/GED required
• Bachelor degree preferred or relevant experience in lieu of degree
• Requires a minimum of ten (10) years combined management experience in the areas of healthcare and clinical operations with an emphasis on delivering clinical programs/health solution interventions to clients in industry.
• Requires a minimum of five (5) years supervisory experience.
• Experience managing multiple projects and complex programs involving cross functional teams required.
• Requires a minimum of five (5) years management experience in the area of healthcare management including Medicaid, ABD or work with chronically and medically fragile members.
• Requires five (5) years of health care management experience, including Medicaid, ABD or work with chronically and medically fragile members
• Requires experience in complying with NCQA and CMS regulations

Additional licensing, certifications, registrations:

• Active Unrestricted NJ RN or SW License Required (other credentials may suffice)

Knowledge:

• Demonstrated proficiency and knowledge in analyzing and interpreting medical management and financial trends.
• Requires knowledge of current Utilization Management, Case Management, and Prior Authorization strategies.
• Requires knowledge of the nature and treatment of diseases and side effects of related therapy methods.
• Requires knowledge of rehabilitation services that include physical, speech and occupational therapy.
• Requires knowledge of the health care delivery system.
• Requires knowledge of case management/clinical program interventions and measures.
• Requires broad clinical knowledge.
• Requires knowledge of current Utilization Management, Case Management, and Pre-Admissions strategies.
• Requires knowledge of the nature and treatment of diseases and side effects of related therapy methods.
• Requires knowledge of rehabilitation services include physical, speech and occupational therapy.
• Requires broad knowledge of Healthcare Maintenance Organization's.
• Requires thorough knowledge of the HMO model and benefit contract.
• Requires broad clinical knowledge.
• Must have knowledge of supportive care principles
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Outlook; Should be knowledgeable in the use of intranet and internet applications.

Skills and Abilities:

• Organizational and leadership skills
• Oral and written communication skills
• Analytical and problem solving skills
• Decision making skills
• Presentation skills
• Analytical skills
• Management skills
• Results Oriented
• Relationship Building & Networking Skills
• Strategic Planning/Thinking

Travel (If Applicable):

• Travel to various Horizon locations and network provider locations as needed.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.