Care Specialist III-Medicaid, Care/Case and Disease Management

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

Job Summary :

This position is accountable for the management of high risk level cases identified through the care management program to ensure effective implementation of interventions, and to ensure efficient utilization of benefits.

Responsibilities :

Conducts high-level assessment and planning for selected population-based members.

Collaborates with the 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 a customized population

Advocates for the member / family among various sites to coordinate resource utilization and

evaluation of services provided.

Interacts with the member / family, physician and healthcare team. Utilizes 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.

Encourages member participation and compliance in the care management program efforts.

Utilizes population-based 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, either telephonically and / or on site striving for continuity and

efficiency as the member is managed along the continuum of care.

Understands fiscal accountability and its impact on the utilization of resources, proceeding to

self-care outcomes.

Evaluates care by problem solving, analyzing variances and participating in the quality

improvement program to enhance member outcomes.

Provides telephonic and / or field based population case management activities specific to the

care management program.

Provides guidance and support to less experienced Care Specialists.

Acts as mentor / preceptor to new hires within the department

Performs user acceptance testing on any process, program and system changes or enhancements, as indicated by leadership

Contributes to overall program execution and success, which includes; active participation in strategic and tactical planning, identifying process improvements as well as creating, developing and implementing revisions

Compliance Statement :

Demonstrates knowledge and understanding of the laws, regulations and policies that pertain to the organizational unit's business and conforms with these laws, regulations and policies in carrying out the accountabilities of the job.

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.

Education / Experience :

High School Diploma / GED required.

Requires a minimum of three (3) years broad clinical experience.

Requires a minimum of two (2) years experience in home care, discharge planning and / or case

management.

No Regulatory Requirement; Active Unrestricted NJ SW License Preferred

Requires a minimum of three (3) years experience in the managed care industry.

Additional licensing, certifications, registrations :

Requires at minimum a current, active, unrestricted New Jersey Certified Social Worker (CSW.) Prefers New Jersey License Social Worker (LSW) or License Clinical Social Worker (LCSW.)

Prefers CCM certification.

May require flexible work hours, time scheduling, travel or on call work specific to the care management program.

Knowledge :

Requires strong knowledge of the standards of practice for case managers.

Requires strong knowledge of managed care principles and concepts including Health Plan Employer Data and Information Sheet (HEDIS).

Skills and Abilities :

Requires strong organizational skills.

Requires strong oral and written communication skills.

Requires good PC skills and the ability to utilize Microsoft Office applications (Excel, Access, Word, etc.)

Requires good problem solving and conflict resolution skills.

Requires good presentation skills.

Requires Project Management Skills

Requires a car with valid New Jersey State License and Insurance for certain positions.

Salary Range : $68,500 - $91,665

$68,500 - $91,665

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.