[Remote] Care Manager I, Specialty Programs

Note: The job is a remote job and is open to candidates in USA. Horizon Blue Cross Blue Shield of New Jersey empowers its members to achieve their best health and is seeking a Care Manager I for Specialty Programs. The role involves performing care coordination duties to ensure appropriate levels of care and planning transitions for specialty populations. Responsibilities • 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. Skills • Requires a license as an RN, or Bachelor degree in social work, health or behavioral science. • Requires a minimum of three (3) years’ experience serving members with special needs. • Requires strong knowledge of the standards of practice for case managers. • Requires strong knowledge of managed care principles. • Requires strong knowledge of specialty population, as applicable. • 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 a car with valid New Jersey State License and Insurance for certain positions. • Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. • Graduate level degree in Social Work or Health and Behavioral Science preferred. Benefits • Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement Company Overview • Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products. It was founded in 1932, and is headquartered in Newark, New Jersey, USA, with a workforce of 5001-10000 employees. Its website is http://www.horizonblue.com. Company H1B Sponsorship • Horizon Blue Cross Blue Shield of New Jersey has a track record of offering H1B sponsorships, with 6 in 2025, 7 in 2024, 6 in 2023, 1 in 2021. Please note that this does not guarantee sponsorship for this specific role. Apply tot his job Apply To this Job