Summary
Overview
Work History
Education
Skills
References
Certification
Timeline
Generic

Eileen Van Horn

Lincoln Park

Summary

Experienced manager specializing in medical policy and managed care with a strong focus on clinical utilization management. Track record of driving team performance and implementing quality control measures to enhance productivity. Demonstrated success in mentoring teams and coordinating projects across departments to maintain regulatory compliance. Committed to achieving operational excellence through strategic leadership.

Overview

34
34
years of professional experience
1
1
Certification

Work History

Manager Medical Policy/Post Service Review

Horizon BCBSNJ
Newark
10.2010 - 01.2026
  • Managed teams of 7 to 20 employees to boost productivity and improve customer service.
  • Resolved customer complaints swiftly, preserving positive brand reputation.
  • Coordinated cross-departmental projects for timely and successful execution.
  • Implemented quality control measures to maintain company standards.
  • Developed training programs enhancing employee skills and knowledge retention.
  • Facilitated meetings addressing progress, challenges, and action plans for team objectives.
  • Monitored staff performance, proactively addressing issues as they arose.
  • Managed inventory for State of NJ contract while overseeing ongoing audit project with external auditors since 2022.

Manager Claim Policy Medical Necessity and Appeals

Horizon BCBSNJ
Newark
02.1998 - 10.2010
  • Monitored staff performance and addressed issues.
  • Coached, mentored and trained team members in order to improve their job performance.
  • Worked directly with departmental medical directors to determine medical necessity decisions, and appeal outcomes.
  • Managed a large team consisting of both clinical analysts and non-clinical support staff. Team size ranged from 10 to 35 employees.
  • Facilitated the clinical response to claims selected for the NCQA audit.
  • Responsible for the inventory management related to fully insured and ASO business.
  • Department liaison to account managers and senior medical directors.

Utilization Review Nurse/Troubleshooter

Horizon BCBSNJ
Newark
10.1995 - 02.1998
  • Reviewed medical records for compliance with established guidelines and policies.
  • Evaluated treatment plans to confirm appropriateness and necessity of services.
  • Monitored pre-authorization requests, ensuring complete information prior to approval or denial.
  • Assessed fifty cases daily, troubleshooting issues as they arose.
  • Coordinated communication between healthcare providers and insurance representatives.
  • Documented findings in utilization review software for precise record-keeping.
  • Provided education to providers on utilization management processes and protocols.
  • Served as a resource for staff seeking guidance on utilization review matters.

Pediatric LPN

Jersey City Medical Center
Jersey City
03.1992 - 10.1995
  • Delivered outstanding care to pediatric patients while educating parents and guardians.
  • The unit consisted of approximately 25 beds, as well as a pediatric ICU unit.
  • Administered medications in accordance with physician's orders.
  • Responded quickly and appropriately during emergency situations.
  • Collaborated with multi-disciplinary team members to develop individualized treatment plans for each patient.
  • Participated in continuing education activities related to pediatrics.
  • Engaged in daily rounds with pediatricians and pediatric specialists.

Education

LPN -

New Jersey City University/JCMC
Jersey City, NJ
03-1992

Skills

  • Written and verbal communication
  • Attention to detail
  • Managed care experience
  • Clinical utilization management
  • ICD-10, CPT-4, HCPCS coding
  • Medical policy knowledge
  • Regulatory guidelines expertise

References

References available upon request.

Certification

Licensed Practical Nurse
License number:
May 2025

Timeline

Manager Medical Policy/Post Service Review

Horizon BCBSNJ
10.2010 - 01.2026

Manager Claim Policy Medical Necessity and Appeals

Horizon BCBSNJ
02.1998 - 10.2010

Utilization Review Nurse/Troubleshooter

Horizon BCBSNJ
10.1995 - 02.1998

Pediatric LPN

Jersey City Medical Center
03.1992 - 10.1995

LPN -

New Jersey City University/JCMC
Eileen Van Horn