Clinical Care Associate

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 position is accountable for providing support to the field based Care Managers (RN II and Care Specialist III). In addition, Clinical Care Associates serve as the first point of contact for our members looking for service and/or provider information as well as members or providers requesting authorizations and denials of services. This position coordinates and secures health care services required as part of a member centric plan of care, under the direction and supervision of the Care Manager.

Responsibilities:

• Assist with scheduling and coordination of service needs identified in the members Plan of Care.  The Clinical Care Associate works with the member to find health care professionals, locate and coordinate health and safety services, schedule appointments and services and provide authorizations and if appropriate, complete denials for care services.
• Assist with all aspects of the implementation and facilitation of services.
• Ensure timely member follow up. Interacts and communicates effectively with the member during telephonic contact.
• Encourages member participation and compliance in the program.
• Assist with placing calls to members. Coordinates the delivery of high quality, cost-effective care based on the members- needs and the managed long term support and services model supported by clinical practice guidelines established by the plan.
• Interacts with the CM member/family, physician and healthcare team. Utilizes the care management process to set priorities, plan, organize, and implement interventions that are goal directed.
• Utilizes care management process for goal directed member care.
• Provides member with educational information to support their health and well-being.
• Documents accurately and comprehensively based on the standards of practice and current organization policies.
• Provides telephonic assistance for activities specific to the program. Troubleshoots and resolve issues for members as well as the field staff they support.
• Professionally and adequately respond to queries from member and provider calls that are received CCA phone queue.
• Mails required documents to members as well as upload returned documents into the medical management system, to meet contractual requirements.

Qualifications:

Education/Experience:

• Requires a High School diploma or GED. Associates or Bachelors degree from an accredited college or university preferred.
• Prefers healthcare industry experience.
• Requires a minimum of one (1) year experience in home care, discharge planning, or case management. Preferably with the elderly frail population.
• Prefer a minimum of one (1) year experience in the managed care industry.

Knowledge:

• Requires knowledge of the standards of practice for care managers, coordination of services, and delivery of services.
• Requires strong knowledge of managed care principles and concepts including Health Plan Employer Data and Information Sheet (HEDIS).

Skills and Abilities:

• Requires strong organizational skills.
• Requires strong oral and written communication skills.
• Requires good PC skills, knowledge of working with a Medical Management system for electronic medical records 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.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all

responsibilities, duties, and skills required of each incumbent.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employ