Healthcare Management

Healthcare Management

Division


The Healthcare Management (HCM) division is responsible for all network development and management, medical care management, pharmacy benefit management and quality management activities related to Commercial, Medicaid and Medicare members on a statewide basis.

HCM is responsible for hospital, physician, pharmacy, ancillary contracting and establishing and maintaining collaborative relationships and related provider audit activities. The goal is to provide members and enrollees with access to a broad network of quality health care services in the most cost-effective manner through competitive contracting, a high degree of medical and quality management and efficient administration.

The division also supports the Company’s efforts to comply with regulatory requirements through targeted oversight and auditing of Company and delegate activities, as well as education and communication.

HCM’s activities support Horizon BCBSNJ’s mission by:

  • Improving the health care experience of our members
  • Providing access to high-quality affordable health care
  • Assessing whether health care services are medically appropriate, have been properly authorized for purposes of coverage and are not under or over utilized
  • Providing information and services to help members make the best decisions about managing their health