Appeals Resolution Analyst

Horizon Blue Cross Blue Shield of New Jersey; Parsippany-Troy Hills (NJ); On-site; USD 45,000 - 60,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an Appeals Specialist to manage basic clinical appeals resolutions for Government Programs. Under supervision, you will ensure timeliness and accuracy while handling the full appeals process and provider/member communications.

You will coordinate with internal teams and external vendors to meet NCQA, DOBI, and state regulatory standards, update authorizations, triage the hotline, and support quality projects aimed at improving care and cost

Qualifications

• Requires high school diploma or GED; Bachelor's degree preferred.
• Experience in acute care medical-surgical or rehabilitation settings is preferred.
• Knowledge of CPT-4 and ICD-9 coding and medical terminology is expected.
• Healthcare insurance experience is a plus.

Responsibilities

• Manage end-to-end appeals process including intake, data entry, external review coordination, and timely resolution.
• Speak with providers and members regarding the appeal process and status.
• Answer and triage the appeal Hotline queue.
• Collaborate with internal and external vendors to ensure regulatory standards are met (NCQA, DOBI, state).
• Update authorizations based on appeals outcomes and ensure timely claim processing.
• Notify internal customers of appeal outcomes and findings.
• Participate in testing and projects to meet department goals.

Skills

Oral and written communication

Analytical thinking

Typing 25 wpm

Medical terminology

Education

High school diploma or GED

Bachelor's degree preferred

Tools

Current Medical Management Systems

Job description

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 basic clinical appeals resolutions for Government Programs and, with supervision, ensuring that timeliness guidelines and accuracy standards are met.

What You’ll Do

• Responsible for the end to end process for appeals, including but not limited to the receipt of appeals, data entry into medical management system, facilitating external review by vendors, and timely case completion.

• Speak to providers and members regarding the appeal process, as well as status of appeals.

• Answer and triage the appeal Hotline phone queue.

• Collaborate with both internal and external vendors to ensure that appeals are processed maintaining NCQA, DOBI, State and all other regulatory standards.

• Update authorizations based on outcome of appeals and ensure that claims are effectuated timely.

• Collaborate with internal customers to ensure that they are notified of the Appeal outcome.

• Perform testing and projects to meet departmental goals.

What You Bring

Education/Experience:

• Requires a High School diploma or GED. Bachelor's degree from an accredited college or university preferred.

• Prefer a minimum of one (1) year recent acute care medical-surgical or rehabilitation experience.

• Prefer one (1) year utilization management experience.

Knowledge:

• Requires knowledge of health care delivery systems.

• Requires knowledge of CPT-4 and ICD-9 coding.

• Requires knowledge of medical terminology

• Healthcare insurance experience preferred.

Skills and Abilities:

• Requires strong oral and written communication skills.

• Requires strong analytical and logical thinking.

• Requires use of good grammar, diction and articulation. 4. Prefer ability to type 25 wpm.

• Experience with Current Medical Management Systems preferred

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives-while being supported by a missiondriven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too.

Salary Range:

$44,600 - $59,745

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.