Clinical Policy & Claims Support Specialist

100 Horizon Healthcare Services, Inc; Hopewell (NJ); On-site; USD 53,000 - 70,000; Full time

Benefits offered by this job

Comprehensive health benefits (Medical

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 Claims Analyst to review medical policies, prepare cases for clinical review, and track information requests to resolve clinical claims and service inquiries.

You will research member records, coordinate clinical reviews and appeals, and ensure accurate pricing and COB updates across all lines of business. Strong analytical, organizational, and communication skills are essential.

Qualifications

• Minimum of a High School Diploma or GED required.
• Three (3) years of health care claims processing experience including researching and investigating customer inquiries.
• 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 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

Communication

Organizational skills

Education

High School Diploma or GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a Claims Analyst to review medical policies, prepare cases for clinical review, and track information requests to resolve clinical claims and service inquiries.

You will research member records, coordinate clinical reviews and appeals, and ensure accurate pricing and COB updates across all lines of business. Strong analytical, organizational, and communication skills are essential.