Medicare/Medicaid Appeals Analyst

100 Horizon Healthcare Services, Inc; Newark (NJ); Vor Ort; USD 63.000 - 84.000; Vollzeit

Benefits dieser Stelle

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Zusammenfassung

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced Analyst to manage end-to-end complaint and appeal cases. You will conduct investigations, ensure regulatory compliance, and document clear decisions for leadership, CMS/state entities, and Administrative Law Judges.

The role involves preparing comprehensive case files, coordinating with external reviewers, and maintaining thorough tracking and documentation.

Qualifikationen

• Bachelor's degree or relevant experience in lieu of degree.
• 4+ years of correspondence and/or telephone customer service experience.
• Experience in health insurance, claim appeals and grievances preferred.
• Experience in complex claims processing required.

Aufgaben

• Prepare comprehensive appeal files and present cases to Leadership Appeals Workgroup; coordinate with external reviewers and ALJ as needed.
• Investigate and analyze member/provider complaints and appeals by gathering documentation and reviewing claim history.
• Apply critical thinking to determine root causes and recommend resolutions with timely written determinations.
• Prepare appeal files for submission to external reviewers and ALJ; ensure all documentation is complete and well organized.
• Review all related calls and summarize findings to support case handling.
• Consult with Legal and Compliance for escalated cases and participate in hearings as needed.

Kenntnisse

Communication

Analytical thinking

Time management

De-escalation

Interpersonal skills

Ausbildung

Bachelor's degree

Tools

CRM systems

NCOMPASS

Jobbeschreibung

Horizon Blue Cross Blue Shield of New Jersey is seeking an experienced Analyst to manage end-to-end complaint and appeal cases. You will conduct investigations, ensure regulatory compliance, and document clear decisions for leadership, CMS/state entities, and Administrative Law Judges.

The role involves preparing comprehensive case files, coordinating with external reviewers, and maintaining thorough tracking and documentation.