DSNP Care Manager - Essex County

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us.

We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

This field based position is accountable for the assessment and case management of Dual Special Needs members using established guidelines to ensure appropriate level of care as well as developing a member centric plan of care.

• Assess patient's clinical needs against established guidelines and/or standards to ensure that the services provided are medically appropriate to members needs.
• Evaluates the necessity, appropriateness and efficiency of services provided.
• Develops, coordinates and assists in implementation of members- individualized plan of care.
• Coordinates with patient, 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.
• Monitors patient'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.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Provides field based and/or telephonic case management activities specific to the Dual Special Needs program.

Education/

Experience:

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires a minimum of three (3) years broad clinical experience.
• Requires a minimum of three (3) years experience in home care, discharge planning, or case management.
• Preferably with the elderly frail population.
• Requires a minimum of three (3) year experience in the health care delivery system/industry.

Additional licensing, certifications, registrations:

• Active Unrestricted NJ SW/RN/LPN License or CSW Required.

Knowledge:

• Requires strong knowledge of the standards of practice for case managers.
• Requires strong knowledge of managed care principles and concepts including Health Plan Effectiveness Data and Information Sheet (HEDIS).
• Required knowledge of medical terminology.
• Prefers knowledge of managed care principles.
• Prefer experience with elderly frail population.

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 ability to work with limited daily supervision.

Travel % (If Applicable):
This is a field based position, daily local travel is required. Requires a car with valid New Jersey State License and Insurance.

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.

We believe that when our people thrive, our communities do too.

Salary Range: $63,000 - $84,420

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…