Healthcare Appeals & Compliance Analyst

Hc; Town of Newark (WI); On-site; USD 63,000 - 84,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement plans

Generous PTO

Tuition reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced complaint and appeal analyst to manage end-to-end cases, investigate thoroughly, and ensure regulatory compliance. You will coordinate with internal teams and external regulators to deliver timely resolutions.

In this role you will analyze trends, document case files for CMS/ALJ review, validate benefits against Evidence of Coverage, and support Medicaid/Medicare compliance.

Qualifications

• High School Diploma or GED required.
• Bachelor's degree preferred or relevant experience in lieu of degree.
• Four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
• Experience in health insurance, claim appeals and grievances preferred.
• Experience in complex claims processing necessary.

Responsibilities

• Prepare comprehensive appeal files and present cases to the Leadership Appeals Workgroup; coordinate submission to independent external reviewers (IRE) and ALJ as needed, ensuring exhibits include claim records, authorizations, research summary, evidence of coverage, timelines, and documentation are complete, accurate, and well-organized. Provides clear, comprehensive explanations of denial decisions, benefit coverage, and case handling.
• Investigate and analyze member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history to validate accuracy, ensure proper configuration and adjudication, and confirm case completeness and compliance with all regulatory, contractual, and organizational requirements.
• Apply critical thinking to determine root cause, validate findings, and recommend appropriate resolutions or corrective actions, while drafting clear, accurate written determinations and correspondence within required turnaround times to ensure messaging is professional and customer-friendly.
• Prepare comprehensive appeal files to be presented to Leadership Appeals Workgroup and for submission to independent external reviewers (IRE), ensuring files include all relevant documentation, claim charts, medical records, Evidence of Coverage, and other Plan documents.
• Search and review all phone calls related to the case and summarize findings.
• Consults with Legal, Compliance and Regulatory Affairs when escalated cases require regulatory review or litigation; may testify on behalf of the organization.
• Validate medical claims by cross-referencing the member’s Evidence of Coverage (EOC) or State Medicaid contract with benefit configuration/coding to confirm services are correctly covered and adjudicated.
• Performs detailed root cause analysis to identify trends, errors, and systemic issues contributing to escalated complaints, then recommends corrective actions and process improvements to prevent future appeals and reduce administrative exceptions.
• Coordinates with all involved business areas to gather facts and ensure a full understanding of the applicable benefit contract.
• Authorizes administrative exceptions, including claim adjustments at higher thresholds, to resolve appeals appropriately.
• Present cases before Leadership Appeals Workgroup and attend Administrative Law hearings, partnering with Legal, to defend appeals before an Administrative Law Judge (ALJ) as needed, ensuring exhibits, timelines, and documentation are complete, accurate, and well-organized.
• Performs other duties as assigned.

Skills

Customer service

Regulatory knowledge

Analytical thinking

Communication skills

Education

High School Diploma/GED

Bachelor's degree

Tools

Microsoft Office Suite

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced complaint and appeal analyst to manage end-to-end cases, investigate thoroughly, and ensure regulatory compliance. You will coordinate with internal teams and external regulators to deliver timely resolutions.

In this role you will analyze trends, document case files for CMS/ALJ review, validate benefits against Evidence of Coverage, and support Medicaid/Medicare compliance.