NJM Insurance Group

Business Analyst

• Provide management and oversight of vendors’ overall performance, contractual compliance adherence to service level agreements and report back to management.
• Utilize the contract management system, create and maintain an inventory of all assigned vendors, which includes contract purpose, contract price, current contract owner and vendor’s service level agreements.
• Work with Law and Regulation on the creation and renewal of existing contracts which includes tracking contract termination notification dates and terms for contracts and ensure that NJM is positioned to renegotiate contract terms or terminate.
• Manage the evaluation, selection, transition, and monitoring of contractual agreements of vendors and coordinate contracts and other legal agreements for the department.
• Be engaged on vendor assessments/selection for new products and service offerings; work with management to negotiate service level agreements, performance/quality metrics and contractual obligations.
• Perform ongoing vendor management activities which include: Resolve vendor problems related to quality, performance, and service level agreements. Escalate to management if SLAs are not met.
• Coordinate status meetings between NJM and Vendor Partners including review of performance tracking measures and results and status of open issues.
• Work with Information Security to perform an annual Risk Assessment for strategic vendor partners, this includes assessment of currency of escrowed software, review of SOC reports, Business Continuity and Disaster Recovery plan and testing results, incident response and data breach response reports, and written information security program.
• Conduct verification of financial stability to include review of annual financial statements, cash flow statements and any open litigation. Verification of monthly invoices and submittal for payment.
• Provide leadership and oversight into vendor project activities to minimize interference with business operations. This includes initial review of project management work products, including charter, project plan, schedule, milestones, risk assessment, change management and escalation process.

Vendor Management Analyst

Analyst

• Handle all Utilization Management medical appeal cases
• Ensure timeliness guidelines are met and appeals handled in compliance with regulatory requirements
• Provide mentoring and clinical liaison support to appeals staff
• Assess patient's clinical need against established guidelines
• Evaluate the necessity, appropriateness and efficiency of medical services
• Perform review of medical records
• Investigate and resolve complicated appeals
• Prepare and present appeals to Appeals Committee
• Document accurately and comprehensively
• Interact and communicate with facilities, physicians and members/families
• Evaluate care by problem solving and analyzing variances
• Facilitate the external review process with the IURO and IRO
• Provide 24/7 on call appeal support as scheduled

Appeals Analyst II – RN

General

• Assesses member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure
• Facilitates response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider
• Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs
• Develops, coordinates and assists in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness
• Coordinates with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
• Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care
• Monitors member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided
• Encourages member participation and compliance in the case/disease management program efforts
• Documents accurately and comprehensively based on the standards of practice and current organization policies
• Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
• Serves as mentor/trainer to new RN's and other staff as needed
• Presents clinical cases during audits conducted by external review organizations
• Performs other duties as assigned by management.

RN II – Primary Nurse Care

• Accountable for the assessment and case management of members to ensure facilitation of health care services
• Assist with implementation and facilitation of services to members in the program
• Collaborates with member/family, physician and all members of the healthcare team, internal and external to this organization
• Coordinates the delivery of high quality, cost-effective care based on the members' needs and the program model supported by clinical practice guidelines established by the plan
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided
• Utilizes the care management process to set priorities, plan, organize, and implement interventions that are goal directed
• Encourages member participation and compliance in the case management program efforts
• Utilizes program case management process for goal directed member/family care
• Documents accurately and comprehensively based on the standards of practice and current organization policies
• Interacts and communicates effectively with member during face to face and/or telephonic contact
• Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes

Care Specialist III – Field Based

• Researches, investigates and coordinates resolution to member and/or provider complaints
• Utilizes IMAC database to extract complaint information and tracking log
• Ensures complaint resolutions meet State timing requirements to ensure compliance
• Gathers data to compile monthly and quarterly statistical reports
• Conducts extensive follow-up with internal areas
• Writes complaint resolution letters to physicians and members
• Reviews the complaint database report weekly and follow-up on outstanding issues
• Completes and/or assist with monthly reporting requirements
• Performs any other duties as assigned by management

Complaint Resolution Analyst

• Lead enterprise change management and adoption planning efforts for service transformation initiatives across Operations
• Ensure organizational readiness, stakeholder alignment, effective communication, and sustainable adoption of business and technology changes
• Develop and execute comprehensive change management strategies that minimize disruption, mitigate risk, and maximize business value
• Conduct stakeholder assessments and impact analyses to identify change impacts and readiness needs
• Coordinate technology releases and operational changes impacting business units
• Identify operational risks associated with business and technology changes
• Measure change adoption, stakeholder engagement, and implementation effectiveness

Specialist, Change Management & Business Readiness

• Conduct end-to-end process reviews across front-office, middle-office, and back-office operations to identify inefficiencies, bottlenecks, and improvement opportunities
• Perform root cause analyses to determine underlying operational issues and identify sustainable solutions
• Design future-state business processes aligned with enterprise service strategies, customer experience goals, and operational objectives
• Develop process maps, workflows, business requirements, and supporting documentation to drive transformation initiatives
• Evaluate and recommend opportunities to simplify, standardize, and optimize operational processes
• Partner with EBTS, Operations, and business stakeholders to translate business needs into effective process and technology solutions
• Support requirements gathering, solution design, and implementation planning
• Ensure business processes and system capabilities are aligned to operational objectives and customer expectations
• Collaborate with cross-functional teams to deliver enterprise transformation initiatives successfully
• Lead and support operational readiness activities for new systems, processes, and business initiatives
• Coordinate business implementation activities, including cutover planning, staffing readiness, workflow transitions, and go-live preparation
• Support User Acceptance Testing (UAT), pilot programs, and post-implementation validation activities
• Assess organizational readiness and identify risks that may impact successful implementation
• Identify opportunities for automation, digitization, and workflow optimization
• Monitor post-implementation performance and identify stabilization issues requiring corrective action

Senior Analyst, Service

• Ensures compliance with federal, state and local tax laws by providing managerial oversight of the company’s tax compliance processes
• Owns and oversees the preparation and review of monthly, quarterly, and annual GAAP and statutory income tax provisions
• Provides leadership for federal and state tax consolidation processes
• Reviews tax-related general ledger account reconciliations prepared by staff
• Leads coordination of state tax audits and directs the preparation of related responses
• Supports the Director, Corporate Tax in the coordination of federal tax audits
• Manages the preparation and review of quarterly and annual GAAP and statutory income tax disclosures
• Oversees the company’s federal, state, and local income and non-income tax compliance processes
• Reviews internally prepared returns and external provider deliverables
• Oversees quarterly state nexus determinations for various taxes
• Reviews and evaluates technical tax research and prepares technical memoranda as needed
• Supervises tax analysts by assigning and prioritizing work and overseeing review processes.

Corporate Tax Manager

Actuary

• Assist in the development and maintenance of premium rates for the Individual and Small Group markets.
• Support the preparation, validation, and submission of premium rate filings to state and federal regulatory agencies.
• Analyze and evaluate proposed benefit design and cost-sharing changes to determine financial and actuarial impacts.
• Conduct pricing analyses, actuarial studies, and financial modeling to support product and rate development initiatives.
• Assess the impact of proposed state and federal legislative, regulatory, and healthcare reform changes on pricing and product strategy.
• Perform Mental Health Parity compliance reviews and support related regulatory reporting requirements.
• Conduct experience analyses and drill-down studies to identify emerging trends, utilization patterns, and key cost drivers.
• Develop ad hoc actuarial models and analytics to support strategic decision-making and business initiatives.
• Collaborate with Product, Finance, Underwriting, Regulatory, Compliance, and other business partners to evaluate assumptions and recommendations.
• Review and analyze data from multiple sources to support actuarial projections and risk assessments.
• Prepare reports, presentations, and recommendations for management, clearly communicating complex actuarial concepts and analytical findings.

Actuarial Analyst III

Network Engineer

• Makes outbound validation calls to providers in order to assure of demographic practitioner detail for each practice location for all Horizon networks.
• Contacts members regarding preventive health activities.
• Receives inbound services calls and provide accurate complete information in response to provider inquiries, complaints and problems within a timely fashion.
• Contact provider offices to encourage ongoing education and dialogue on data management best practices to service member/patient needs and to attend scheduled orientation sessions and other educational and outreach activities.
• Conducts provider surveys and assessments as applicable.
• Act as liaison with providers, members and outside community resources.
• Handle PCP/PCD changes for members.
• Verification of PCP/PCD and member eligibility with Providers.
• Maintain call documentation in databases with relevant information regarding special outreach projects in accordance with departmental focus and objectives.
• Assist provider offices with issues associated to credentialing, recredentialing, claims and provider data maintenance by providing guidance on how to proceed with the process.

Network Outreach Specialist I

• Assess member's clinical need against established guidelines and/or standards to ensure that the services provided are medically appropriate to member's needs and aligned with the benefit structure
• Facilitate response to gaps in care and identified high risk members to appropriate settings of care for annual wellness visits including collaboration with treating provider
• Evaluate the necessity, appropriateness and efficiency of medical services and procedures provided for both acute and chronic health care needs
• Develop, coordinate and assist in implementation of individualized plan of care for members and identification of barriers towards Self-Management and optimal wellness
• Coordinate with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
• Coordinate the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care including transitional care
• Monitor member's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
• Advocate for the member/family among various sites to coordinate resource utilization and evaluation of services provided
• Encourage member participation and compliance in the case/disease management program efforts
• Document accurately and comprehensively based on the standards of practice and current organization policies
• Interact and communicate with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care
• Evaluate care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
• Serve as mentor/trainer to new RN's and other staff as needed
• Present clinical cases during audits conducted by external review organizations
• Perform other duties as assigned by management

RN II – Primary Nurse Care, Case Management

• Develop a housing strategy for Horizon membership (specifically MLTSS/SNP/Medicaid)
• Identify and manage resources for housing options
• Provide education to all relevant staff, Care Management, Member Advocates and Utilization Management on housing options and resources.
• Assist with locating and placing members in appropriate housing, facilitating transitions to community settings.
• Complete reports to meet the state requirements; including but not limited to progress towards goals, quality monitoring.
• Act as a liaison with DMAHS staff or its designee to receive training and capacity building assistance.
• Must work closely with relevant public and private housing resources and stakeholders, including but not limited to HUD subsidized housing, all Department of Community Affairs (DCA), New Jersey Housing and Mortgage Finance Agency (NJ HMFA) housing program voucher programs, public housing authorities, realtors, and online housing locator resources.

Housing Specialist

Manager

• Performs RN duties using established guidelines to ensure appropriate level of care
• Plans for the transition to the continuum of care
• Assesses patient's clinical need against established guidelines
• Evaluates the necessity, appropriateness and efficiency of medical services
• Coordinates and assists in the implementation of care plans for members
• Monitors and coordinates services rendered outside of the network
• Advocates for members among various sites to coordinate resource utilization
• Documents accurately based on the standards of practice
• Acts as a subject matter expert for projects and committees
• Serves as mentor/trainer to new RN's and staff as needed

RN II, Case Manager – Pediatrics

General Counsel

• Responsible for assisting on transactional matters, including commercial contracts and negotiations pertaining to the Company’s supplier, services, and real estate.
• Advise/counsel across assigned functions related to the organization’s legal rights and obligations.
• Provide legal counsel in business-related areas of expertise and identify/assess risk.
• Research, analyze, and interpret proposed and existing laws, statutes, and regulations.
• Structure, draft, negotiate and/or approve legal contracts, letters of agreement, policies and other documents related to operational matters.
• May be accountable for liaising with external legal counsel on complex legal issues.
• Liaison with regulators in certain jurisdictions, as necessary.
• Perform other miscellaneous responsibilities and duties as assigned or directed.

Corporate Counsel

Consultant

• Key member of account management team in its efforts to sell new business, inclusive of ancillary products
• Service, convert, and add additional lines of business to existing accounts and convert accounts to managed care
• Create and facilitate client presentations and meetings, utilizing analysis of current client trends and plan design offerings
• Analyze data in order to recommend changes and cost saving designs incorporating medical management programs
• Responds timely and proactively to account or broker telephone inquiries by contacting the appropriate operating areas throughout the enterprise
• Must build strong internal and external relationships
• Resolves complex service issues, and answers product and benefits questions
• Assists in processing paperwork relating to the prospecting, enrollment, and/or termination of accounts
• Maintains the accuracy of the account profile and group administration through data updates
• Facilitates and coordinates the timely implementation of new groups and conversions
• Analyzes inter-departmental problems and makes recommendations for resolutions
• Assists in the procurement of information from groups to complete and verify sale documentation
• Responsible for reporting requests and confirming data accuracy
• Performs other duties as assigned by management