Clinical Policy & Claims Support Specialist

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (NJ); Presencial; USD 53.000 - 70.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Comprehensive health benefits (Medical

Dental

Vision

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Descripción de la vacante

Horizon Blue Cross Blue Shield of New Jersey is seeking a dedicated professional to review medical policies, prepare cases for clinical review, and manage information requests to resolve claims and service inquiries across all lines of business. You will research member records, coordinate clinical reviews and appeals, and ensure accurate pricing and COB updates.

Strong analytical and communication skills are essential as you support a mission-driven organization focused on quality care and

Formación

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

Responsabilidades

• 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.

Conocimientos

Analytical thinking

Organizational skills

Communication skills

Educación

High School Diploma or GED

Descripción del empleo

Horizon Blue Cross Blue Shield of New Jersey is seeking a dedicated professional to review medical policies, prepare cases for clinical review, and manage information requests to resolve claims and service inquiries across all lines of business. You will research member records, coordinate clinical reviews and appeals, and ensure accurate pricing and COB updates.

Strong analytical and communication skills are essential as you support a mission-driven organization focused on quality care and