RN, Data Analyst

Horizon Blue Cross Blue Shield of New Jersey is hiring an RN Data Analyst for its centralized stop loss team in Newark, NJ. In this onsite role, you will support stop loss risk management activities and coordinate risk oversight with care delivery teams for high risk members, using established guidelines and reporting tools to promote medically necessary care and appropriate transitions.

What you’ll do

• Partner with care management and delivery functions to identify potential high risk patients in new business and renewal groups, and assess clinical need against established guidelines to help ensure appropriate care levels.
• Engage potential high risk claimants in care management protocols and coordinate outreach across internal and external stakeholders.
• Work with sales and account management, brokers, consultants, and group customers to support care management engagement for high risk members.
• Provide special coordination for supporters of high risk patients, including immediate and extended family and employers, as appropriate.
• Use reporting and risk identification tools on medical and pharmacy claims to assess risk, and support risk mitigation and high claimant detection activities.
• Help ensure care management protocols are maintained for members receiving care outside Horizon BCBSNJ’s service area, including the use of resources such as transplant centers and centers of excellence where appropriate.
• Assist utilization management (UW) in evaluating risks in existing and potential stop loss groups.
• Collaborate with pharmacy management to support efficient and appropriate specialty drug usage and site of service delivery.
• Evaluate care by analyzing variances, solving problems, and participating in the quality improvement program to enhance member outcomes.
• Support preferred partners by responding to inquiries requiring additional information on large claimants.
• Serve as a resource to sales and account management teams by communicating how case management services interact with stop loss management.
• Perform other duties as assigned by management.
• Identify and manage high risk claimants within established and prospective stop loss customers, and engage functional areas of the company and care delivery systems for high risk claimant management.

Key skills and qualifications

• Minimum high school diploma or GED.
• Prefer an Associate’s or Bachelor’s degree (or higher) in nursing and/or a health related field, or an accredited diploma nursing school credential.
• Must have an active NJ Registered Nurse License.
• Prefer pending or obtained case management certification or other applicable clinical specialties.
• Minimum two (2) years of clinical experience.
• Minimum three (3) years of experience in the health care delivery system/industry.
• Minimum two (2) years of experience with health care payer experience.
• Prefer advanced Excel, SQL, or Tableau, including experience creating dashboards and reports.
• Requires understanding of health and prescription insurance products, contracts, and benefits eligibility.
• Requires understanding of health delivery systems and professionals.
• Requires understanding of case/care/disease management principles.
• Understanding of stop loss reporting tools and requirements is preferred.
• Understanding of risk mitigation, high claimant detection, engagement, and management is preferred.
• Strong interpersonal skills with ability to work across divisions and with external stakeholders.
• Proficiency with personal computers and Windows-based environments, including MS Office (Word, Excel, PowerPoint, MS Project) and Lotus Notes.

Tools you may use

• Excel, SQL, Tableau
• Dashboards and reporting
• MS Office (Word, Excel, PowerPoint, MS Project)
• Lotus Notes
• Windows

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Location: Newark, NJ (onsite)

Salary range: $79,100 - $105,945 per year

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