Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware Job Summary: This position is responsible for ensuring documented operational compliance to state, federal and accreditation standards in Utilization Management and/or Case Management. Is the subject matter expert in UM and/or CM for DOBI, IPRO, CMS and NCQA. Maintain library of policies and audit documentation. Track and trend operational deficiencies identified by internal and external regulatory/accreditation audit and identify and implement opportunities for improvement. Responsible for training and education as applicable. Responsibilities: Ensure operational compliance to state and federal contracts and accreditation standards for UM and/or CM. Analyzes complex data and information to provide meaningful results, identifying success factors and improvement opportunities, recommending potential solutions to assist the business set strategic goals. Interacts with internal and external stakeholders to promote HCM&T clinical and operational improvement activities. Act as department subject matter expert (SME) for DOBI, IPRO, CMS, NCQA and internal audit preparation and review. Maintain up to date library of core operational documents for NCQA audit readiness. Act as Subject Matter Expert (SME) with Legal, Regulatory, Compliance, Quality and other departments as applicable on contract changes and audit compliance. Track and Trend data on audit deficiencies and identify and implement opportunities for improvement. Responsible for the accuracy and timely submission of quarterly regulatory reports. Responsible for implementation of department Corrective Action Plans. Develop, maintain and update Operational Policies for UM and/or CM to ensure compliance to applicable federal and state regulations and national accreditation standards. Develop streamlined process for the review and approval of policies utilizing applicable programs within Horizon. Identify opportunities to align policies across all lines of business. Educate on policy and contract changes and ensure applicable operational procedures/ job aids are updated for compliance. Lead for staff education and training related to NCQA/DOBI/IPRO/CMS standards and related audit findings. Other duties as assigned The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent. Education/Experience: Requires a Bachelor's Degree in Nursing, Health Management or related field. Requires three years professional business experience working in a clinical insurance environment. Requires five (5) years UM and/or CM experience in a managed care environment Requires experience with data related applications in the PC environment is also required. Additional licensing, certifications, registrations: Active Unrestricted NJ RN License or NJ Licensed Social Worker Required Knowledge: Requires knowledge of Utilization Management (UM)/ Case Management (CM) and managed care principles. Requires knowledge of health care systems and medical documentation. Requires knowledge of State Mandates and Regulations. Requires knowledge of regulatory bodies and their processes. Requires knowledge of NCQA accreditation standards. Requires knowledge of project management methodology. Skills and Abilities: Requires strong analytical abilities and the ability to report findings accurately Requires the ability to apply project management methodologies and practices across multiple projects. Requires excellent verbal and written communications skills. Requires strong interpersonal skills and the ability to interact with all management levels. Require excellent presentation skills. Requires excellent organizational skills Requires strong analytical abilities and the ability to report findings accurately. Requires the ability to utilize logic in problem solving. Must be proficient in the use of personal computers and supporting software in a Windows based environment including MS Office products (Word, Excel, PowerPoint) SharePoint and Outlook; Required knowledge in the use of intranet and internet applications. Salary Range: $76,800 - $102,795 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. About Us We are the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too. Our Mission We empower our members to achieve their best health. Our Vision We are New Jersey’s health solutions leader driving innovations that improve health care quality, affordability and member experience in the markets we serve.