Clinical Policy & Claims Support Specialist

Horizon Blue Cross Blue Shield of New Jersey; Oregon; Hybride; USD 53 000 - 70 000; Plein temps

Avantages offerts par ce poste

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Résumé du poste

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced professional to review medical policies, prepare cases for clinical review, and track information requests for end-to-end resolution of clinical claims and service inquiries.

You will research member medical records, coordinate clinical review and appeals, and determine pricing and COB updates while handling inquiries and supporting management with other tasks as assigned.

Qualifications

• High school diploma or GED required.
• 3+ years of health care claims processing experience.
• 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.

Responsabilités

• Review member records to resolve claims tied to clinical edits.
• Review medical policies to guide claim processing decisions.
• Coordinate clinical review and appeals by gathering information.
• Draft letters and process updates for claim adjustments.
• Update COB files and provider data as needed.
• Handle relevant inbound inquiries as needed.
• Perform other tasks as assigned by management.

Connaissances

Analytical thinking

Organizational skills

Communication skills

Description du poste

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced professional to review medical policies, prepare cases for clinical review, and track information requests for end-to-end resolution of clinical claims and service inquiries.

You will research member medical records, coordinate clinical review and appeals, and determine pricing and COB updates while handling inquiries and supporting management with other tasks as assigned.