NJM Insurance Group

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

Account Consultant II – National Accts

Bilingual

• Supports the Clinical Operations functions and acts as a liaison between members, physicians, delegates, operational business members and member service coordinators
• Responsible for providing leadership and guidance to non-clinical team and handle escalated issues/problems
• Performs review of service requests for completeness of information
• Collect and collate information required to handle escalated inquiries
• Assists members with finding providers and answering questions regarding services
• Makes outbound calls to engage members in Case Management

Managed Care Coordinator II – Bilingual, Spanish Speaking

Business Operations

• Support the execution of strategic business process initiatives collaborating with cross-functional teams
• Support the launch of new products and services
• Maintain business process documentation and assist in optimizing business processes
• Provide support to business users for process and technology adoption
• Monitor and triage end-user support requests
• Collaborate with technology teams and solution owners to resolve incidents
• Ensure seamless transition of technology initiatives to business users
• Assist with change management and rollout of new products and technologies

Business Process Operations Analyst I

Operations

• Manage and maintain a high-quality enterprise sales pipeline.
• Implement and enforce BANT qualification processes.
• Drive CRM accuracy, hygiene and forecasting discipline.
• Create operational cadence for pipeline reviews, opportunity progression, follow-up management and sales reporting.
• Ensure all opportunities are progressing efficiently through the funnel.
• Build, maintain, and continuously refine a lead scoring model in Salesforce.
• Leverage AI tools to accelerate prospecting, research, account targeting, and personalized outreach at scale.
• Partner closely with Marketing to convert inbound and outbound campaigns into qualified enterprise meetings.
• Support enterprise deal orchestration and account strategy.
• Prepare briefing materials and opportunity summaries for executive meetings.
• Directly manage junior growth team members and coach them on enterprise sales process discipline.

Manager, Growth Operations

Business Intelligence Analyst

• Evaluate, write, and present utilization and cost containment reports
• Determine or agree upon deliverables with customer
• Liaison with IT/vendor and customer
• Perform analysis on data: forecasting, modeling, regression
• Mine data from appropriate system
• Present data and provide feedback to client and customer
• Develop relationships with subject matter experts (SME)
• Seek and adopt best practices in data reporting
• Perform other relevant tasks as assigned by Management

Data Reporting Analyst II

Call Center Representative

• Provide excellent service to customers through the resolution of basic customer inquiries received by phone or though written correspondence.
• Receive customer inquiries via phone, fax, mail, e-mail, etc.
• Probe for additional helpful information to effectively handle inquiry.
• Review computer systems and/or other reference materials to complete verification process.
• Initiate investigation process based on the nature of the inquiry (claim, member information, benefits, enrollment, appeals, etc.).
• Utilize available resources to resolve or redirect inquiries in accordance with departmental process.
• Document customer inquiries and actions taken to ensure appropriate follow up.
• Follow up on unresolved issues in a timely manner, escalating call trends to management.
• Deliver an excellent customer service experience while meeting quality and production standards.

Call Center Service Associate

Paralegal

• Provide litigation or transactional support under minimal supervision
• Research, monitor, update, and maintain current knowledge of developments in federal and state legislation, rules, regulations, enforcement actions and industry guidelines affecting the health insurance industry
• Organize, maintain and update departmental files
• Prepare legal documents for review, approval, and use by attorneys, as requested
• Analyze data and write reports as requested
• Provide administrative assistance as needed
• Perform factual investigation and research
• Assist in obtaining, organizing, analyzing and providing documents and information related to the litigation, investigation or subpoena
• Negotiate resolution of matters pursuant to authorized authority

Paralegal III

Learning and Development

• Partner with the Talent Development Team, HR Business Partners and other relevant stakeholders to identify performance gaps, design customized learning solutions, etc.
• Deliver formal and informal learning solutions, including presentations, workshops, training, and events via both in-person and virtual platforms
• Lead and facilitate large-scale events and programs
• Apply project management skills to organize resources for all phases of projects
• Develop evaluation tools to evaluate learning program outcomes and job-relatedness of training
• Conduct follow-up surveys and/or interviews with participants and managers to evaluate program impact
• Assist TD Management with sourcing and vendor selection
• Conduct evening new hire orientation on rare occasion, if required

Senior Talent Development Specialist

Analyst

• Supports the Health Services and Utilization Management functions
• Acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators
• Prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings
• Mentors more junior staff by responding to questions and sharing expertise
• Adheres to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows
• 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
• Manages correspondence of toll-free UM Appeal hotline and UM Appeal fax server
• Interacts with and supports Medical Directors
• Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors
• Prepares, documents and routes cases in appropriate system for clinical review
• Responsible for the comprehensive explanation of previous denials, the scope of coverage, and applied criteria
• Conducts and provides root cause analysis to avoid future appeal occurrences.

UM Appeals Analyst – MAC

Auditor

• Develops scope and work programs, assigns tasks, and ensures task accomplishment
• Identifies, develops and documents control issues
• Monitors ongoing performance and develops updates to recommendations
• Prepares formal written reports expressing opinions on internal control adequacy
• Builds strong relationships and gathers business risk information
• Oversees staff work to ensure quality and client satisfaction
• Reports progress of assigned audits and seeks input from management

Auditor III

Manager

• Perform RN duties for Primary Nurse population
• Outreach to high risk members for preventative care opportunities & screenings
• Develop member centric plan of care
• Assess member's clinical needs against established guidelines
• Coordinate delivery of high quality, cost-effective care
• Monitor member's medical care activities for appropriateness and effectiveness

RN II, Primary Nurse Care – Case Manager

• Responsible for performing 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.
• Coordinates and assists in implementation of plan for members.
• Monitors patient's medical care activities and outcomes for appropriateness and effectiveness.
• Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
• Serves as mentor/trainer to new RN's and other staff as needed.
• Represents clinical teams within committee meetings.

RN II, Case Manager

• Assess member’s clinical need against establish guidelines and/or standards for specialty population-based members.
• Implement the delivery of high quality, cost-effective care based on a customized population model of care supported by clinical practice guidelines established by the plan.
• Partner with the member/family, physician, and all members of the healthcare team to ensure the member’s needs are met, internal and external to this organization.
• Advocate for the member among various sites to coordinate resource utilization.
• Utilize the care management process to set priorities, plan, organize, and implement interventions that are goal directed toward self-care outcomes, and the transition to independent status.
• Ensure care for mandated non-compliant members through the monitoring of utilization.
• Document accurately and comprehensively based on the standards of practice and current organization policies.
• Evaluate care by problem solving, analyzing variances, and participating in quality improvement to enhance member outcomes.
• Monitor member’s care activities, regardless of the site of service or network participation, and outcomes for appropriateness and effectiveness.
• Consult with internal stakeholders on complex cases and escalate as appropriate to internal physician resources.
• Complete other assigned functions as requested by management.

Care Manager I, Specialty Programs

• Monitor current day call queues and real-time performance metrics of the contact center
• Adjust and allocate resources to meet fluctuating demands and ensure that contact center goals are met
• Administer contingency action plans when deemed necessary
• Provide real-time updates and insights to management
• Manage WFM mailboxes and hotline to make timely skill changes and schedule updates to reflect accurate intraday projections
• Collaborate with team leaders to optimize staffing and scheduling
• Maintain accurate records of operational data and prepare daily reports
• Perform additional tasks and project-related work as business needs dictate

Real Time Scheduling Analyst

• Deliver accurate variance reports of various financial activities and demonstrate expert skills around analyzing and interpreting financials using statistical, financial, and operational data
• Explain and correct data variances and fluctuations
• Highlight issues and offer solutions to routine problems
• Prepare and review ad hoc analysis and benchmarking for assigned divisions or companies including analyzing financial and member data as well as compiling reports, graphs and presentations
• Lead complex analysis and detailed variances driving changes in accounts receivable
• Serves as a lead to the junior analysts and ensure the timely and accurate processing of monthly activities
• Verify certain the General Ledger balances to ensure complete, accurate and efficient financial reporting