Horizon Blue Cross Blue Shield of New Jersey Looking for UM Operations Coordinator at Hopewell, NJ  / Wall, NJ  Full Time

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

Job Summary:

This position will provide direct guidance and support to team members and act as the subject matter expert within a specific functional area of Clinical Operations. This position is responsible for processing utilization management request in the Medical Management System, analyzes workflows to ensure efficiencies and complete special projects assigned by management.

Responsibilities:

• Performs the following job responsibilities under the direction/supervision of an RN; 1. Review and resolve complex claims processing issues and utilization management cases, ensuring accurate and timely prior authorization of designated healthcare services, concurrent review activity, and retrospective review activity.
• Works collaboratively with Provider Contracting & Servicing on system issues for the provider network or other identified needs.
• Provide additional research and support for complex claims as requested by Medical Directors to make a final decision/recommendation.
• Determining member’s clinical and non-clinical needs against established guidelines and/or standards to ensure the level of care and length of stay of the patient are medically appropriate for inpatient stay.
• Accept telephonic, mail, faxed and automate system reviews. Appropriately document the review including: diagnoses, procedures, specialists, treatment and plan, used to justify the approval of request.
• Provides onboarding training for Managed Care Coordinators I & II, as subject matter expert. Support the nesting process for smooth post training transition and monitor ongoing training to ensure staff member meeting unit needs. Perform audits and retraining of non-clinical staff and new staff.
• Provides telephonic assistance and education to Providers on the UM process
• Collaborate with stakeholders to develop and deliver learning solutions in support of clinical and non-clinical processes, new products, product updates and/or other business initiatives.
• Assist Supervisor in developing cost reduction solutions and process efficiencies. Identify trends, recommend changes to processes including workflows, assess process deficiencies.
• Responsible for filing formal Account Disclosure forms
• Responsible for special projects assigned by supervisor
• Responsible for performing vendor customer service tasks.

Education/Experience:

• Prefers a Bachelor’s degree from an accredited college or university, preferably in healthcare, or related field. In lieu of degree applicant must have an additional 4 years of equivalent and relevant work experience.
• Prefers a minimum of one-year clinical experience in an acute care facility or healthcare setting.
• Requires a minimum of one-year experience in the health care delivery system/industry.

Additional licensing, certifications, registrations:

• LPN, or clinical certification preferred.

Knowledge:

• Knowledge of medical terminology
• Prefer knowledge of current Horizon payment and claims systems or health insurance products and insurance terminology
• 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 Lotus Notes; Should be knowledgeable in the use of intranet and internet applications.
• Knowledge of state and federal regulations related to managed care industry, preferably in the areas of government programs.
• Knowledge of the regulatory environment and requirements.

Skills & Abilities:

• Requires excellent oral and written communication skills.
• Requires excellent organizational skills.
• Requires the ability to use sound judgment and resolve problems with moderate guidance from lead staff and/or supervisor.
• Requires strong analytical skills and the ability to use sound judgment and resolve problems with minimal guidance or supervisor.
• Requires strong interpersonal skills.
• Requires the skill to communicate effectively to all levels of employees.
• Require the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.
• Requires good PC skills and the ability to manage applicable software.
• Strong interpersonal skills

Salary Range:

$53,500 – $71,610

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

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.