Appeals Analyst — Generous PTO & Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey; Newark (NJ); On-site; USD 63,000 - 84,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a skilled analyst to manage end-to-end complaint and appeal cases, ensuring regulatory compliance and clear, defensible decisions. You will work with internal stakeholders and state agencies to deliver timely resolutions, supporting Medicaid and Medicare considerations and improving member experience.

Responsibilities include preparing case files for leadership and ALJ review, documenting trends, and presenting findings.

Qualifications

• Bachelor's degree preferred or relevant experience in lieu of degree.
• Four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
• Experience in health insurance, claim appeals and grievances preferred.
• Experience in complex claims processing necessary.

Responsibilities

• Prepare comprehensive appeal files and present cases to leadership; coordinate with external reviewers and ALJ as needed.
• Investigate and analyze member/provider complaints and appeals using documentation, interviews, and claim history.
• Apply critical thinking to determine root cause and draft clear written determinations within turnaround times.

Skills

Clear communication

Analytical skills

Deescalation techniques

Time management

Education

Bachelor's degree preferred

High School Diploma/GED required

Tools

CRM systems

Microsoft Office

Claims systems

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a skilled analyst to manage end-to-end complaint and appeal cases, ensuring regulatory compliance and clear, defensible decisions. You will work with internal stakeholders and state agencies to deliver timely resolutions, supporting Medicaid and Medicare considerations and improving member experience.

Responsibilities include preparing case files for leadership and ALJ review, documenting trends, and presenting findings.