Clinical Policy & Claims Review Specialist

Horizon Blue Cross Blue Shield of New Jersey; United States; Remote; USD 53,000 - 70,000; 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 seeks a detail-oriented professional to review medical policies, prepare cases for clinical review, and track information requests to resolve clinical claims and service inquiries. This role supports end-to-end processing across all lines of business in a health plan environment.

The successful candidate will have at least three years of health care claims processing experience, two years in medical terminology, billing and coding, and familiarity

Qualifications

• Minimum of a High School Diploma or GED equivalent.
• Three (3) years of health care claims processing experience.
• Two (2) years of experience with medical terminology, billing and coding.
• Knowledge of COB and Horizon medical policies preferred.
• Knowledge of all lines of business preferred.

Responsibilities

• Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business.
• Review medical policies and determine the appropriate claim processing or clinical review process decisions.
• Coordinate the clinical review and appeal processes including; preparing cases for clinical review and requesting additional information from members and providers.
• Review clinical determinations and initiate appropriate claim adjustments and service requests closeout, including drafting manual letters.
• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements.
• Review and update Coordination of Benefit (COB) files and submit provider file updates as necessary.
• Identify technical issues and submit to the appropriate area for resolution.
• May handle relevant incoming telephone inquiries.
• May perform other tasks as assigned by management.

Skills

Analytical thinking

Organizational skills

Communication skills

Education

High School Diploma or GED

Job description

Horizon Blue Cross Blue Shield of New Jersey seeks a detail-oriented professional to review medical policies, prepare cases for clinical review, and track information requests to resolve clinical claims and service inquiries. This role supports end-to-end processing across all lines of business in a health plan environment.

The successful candidate will have at least three years of health care claims processing experience, two years in medical terminology, billing and coding, and familiarity