Care Manager I, Specialty Programs- Behavioral Health

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.

The Care Manager I – Specialty Programs is responsible for performing care coordination duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care for specialty populations. This position implements interventions to ensure efficient utilization of benefits.

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. 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.