Entry Appeals Analyst - Health Plan Compliance

Horizon Blue Cross Blue Shield of New Jersey; Parsippany-Troy Hills (NJ); On-site; USD 63,000 - 84,000; 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 experienced Analyst to manage end-to-end complaint and appeal cases. You will investigate thoroughly, ensure regulatory compliance, and prepare clear, defensible decisions for leadership and external reviews.

You will collaborate with internal and external stakeholders, support Medicaid/Medicare compliance, and contribute to improving member experience through detailed tracking and analysis.

Qualifications

• Bachelor degree preferred or relevant experience in lieu of degree.
• Four+ years of correspondence and/or telephone customer service experience.
• Experience in health insurance, claim appeals and grievances preferred.
• Experience in complex claims processing necessary.
• Knowledge of Medicare/Medicaid regulations and guidelines.
• Strong MS Office skills.

Responsibilities

• Prepare comprehensive appeal files and present cases to leadership; coordinate with external reviewers and ALJ.
• Investigate and analyze member/provider complaints and appeals with documentation review.
• Apply critical thinking to determine root cause and recommend resolutions.
• Prepare files for external review; ensure complete documentation and exhibits.
• Summarize calls and interactions related to each case.
• Consult with Legal, Compliance and Regulatory Affairs when escalations occur.
• Validate claims against Evidence of Coverage and contract terms.

Skills

Customer service

Investigation

Regulatory compliance

Grievances handling

Communication

Analytical thinking

Timeliness

Multitasking

Case management

Education

Bachelor degree preferred or relevant experience in lieu of degree

Tools

NCOMPASS CRM

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced Analyst to manage end-to-end complaint and appeal cases. You will investigate thoroughly, ensure regulatory compliance, and prepare clear, defensible decisions for leadership and external reviews.

You will collaborate with internal and external stakeholders, support Medicaid/Medicare compliance, and contribute to improving member experience through detailed tracking and analysis.