Horizon Blue Cross Blue Shield of New Jersey

This role involves performing RN duties using established guidelines to ensure appropriate levels of care and planning for transitions across the continuum of care, including assessing clinical needs against standards for inpatient stays. Responsibilities also cover evaluating medical services, coordinating care plans, monitoring out-of-network services, and advocating for member needs.

The Program Lead is responsible for the overall oversight of all Federal Employee Program (FEP) related activities within Special Investigations, ensuring compliance with FEHB Carrier Letter and BCBSA Anti-Fraud policies. This role involves leading and managing annual FEP certifications, presenting findings to executive management, and leading healthcare fraud investigations impacting the FEP.

Lead Quality Management Clinical Operations and Audit, focusing on HEDIS and Stars performance. Develop policies, manage staff, and improve quality initiatives.

The Digital Product Manager manages digital assets, prioritizes product backlogs, and collaborates with cross-functional teams to enhance user experience and efficiency.

Responsible for billing, accounting, payment posting, invoice preparation, reconciliations, and maintaining General Ledger integrity. Ensures timely payments and resolves billing discrepancies.