Quality Management Specialist

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.

About the Role

This position is responsible for supporting the Quality Management department with improvements through project planning, development and implementation, and the establishment of policies and procedures pertaining to regulations in both Government Programs and Commercial business.

What You'll Do

• SAS & SQL Coding Experience HIGHLY PREFERRED
• Develop project initiatives, process and performance measures for Quality Management and deliverables to ensure positive outcomes defined by corporate objectives and NCQA and regulatory regulations.
• Analyzes complex data and information to provide meaningful results, identifying success factors and improvement opportunities, recommending potential solutions to assist the business set strategic goals.
• Responsible for budgeting, cost containment and strategic planning of systemic enhancements to improve the quality and efficiency of project initiatives and yearly interventions.
• Collaboratively serve as a HCM&T divisional resource with the Manager for health plan quality ratings.
• Interacts with internal and external stakeholders to promote HCM&T clinical and operational improvement activities.
• Measure performance goals of Medicare STAR Program plans and initiatives to ensure effectiveness of process. Report findings to management and stakeholders as appropriate.
• Reviews all HPMS and industry correspondence, related to Star Ratings in order to assist and remain current on all information and decision. Ensures that all information necessary for decision making is coordinated and any necessary documentation is prepared.
• Provide Consumer Assessment of Healthcare Providers and Systems (CAHPS) coaching to the Horizon providers community to improve the member experience.
• Interprets member experience performance through various sources of data.
• Assist in the development of provider improvement action plans to improve member experience and improve CAHPS performance.

What You Bring Education/Experience:

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree.
• Requires five (5) years professional business experience working in a health care environment.
• Prefer five (5) years managed care experience.

Knowledge:

• Requires knowledge of project management methodology.
• Requires knowledge of healthcare management.
• Requires working knowledge of PC and application software.
• Requires knowledge of performance measurement and regulatory reporting.
• SAS Coding experience strongly preferred.
• HEDIS/Quality Initiative experience strongly preferred.
• State Reporting experience strongly preferred.

Skills and Abilities:

• Requires the ability to apply project management methodologies and practices across multiple projects.
• Requires comprehensive leadership and decision making ability.
• Requires excellent analytical and problem solving skills.
• Requires excellent verbal and written communications skills.
• Require excellent presentation skills.

Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $97,800 - $133,455 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

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

Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. Apply tot his job Apply To this Job