Health Insurance Appeals Analyst I

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (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

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks an experienced analyst to manage end-to-end complaint and appeal cases, ensure regulatory compliance, and prepare defensible decisions. The role coordinates with internal and external stakeholders and supports Medicaid/Medicare compliance, including Medicare STARS impacts.

The Analyst will prepare comprehensive case files for review by leadership, CMS/state entities, and ALJs, maintain tracking, analyze trends, and drive quality improvements in

Qualifications

• High school diploma required; bachelor preferred or relevant experience.
• Four+ years of correspondence or telephone customer service experience.
• Experience in health insurance, claim appeals and grievances preferred.
• Experience in complex claims processing required.

Responsibilities

• Prepare comprehensive appeal files and present cases to leadership and reviewers.
• Investigate member/provider complaints and appeals via documentation and interviews.
• Analyze benefit, billing, and service issues and ensure regulatory compliance.
• Draft clear written determinations and correspondence within turnaround times.
• Coordinate with Legal, Compliance, and Regulatory Affairs as needed.
• Present cases before leadership and attend ALJ hearings when required.

Skills

keyboarding proficiency

strong language proficiency

clear written communication

active listening

time management

deescalation techniques

Education

High School Diploma/GED

Bachelor degree preferred

Tools

NCOMPASS

Microsoft Office Suite

Job description

Horizon Blue Cross Blue Shield of New Jersey seeks an experienced analyst to manage end-to-end complaint and appeal cases, ensure regulatory compliance, and prepare defensible decisions. The role coordinates with internal and external stakeholders and supports Medicaid/Medicare compliance, including Medicare STARS impacts.

The Analyst will prepare comprehensive case files for review by leadership, CMS/state entities, and ALJs, maintain tracking, analyze trends, and drive quality improvements in