Policy Support Specialist — Clinical Claims & Review

Horizon Blue Cross Blue Shield of New Jersey; Parsippany-Troy Hills (NJ); On-site; USD 53,000 - 70,000; Full time

Benefits offered by this job

Comprehensive health benefits (Medical

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a detail‑oriented Claims Specialist to review medical policies and manage clinical inquiries from members and providers.

You will coordinate clinical review, request information, and help finalize claims while ensuring compliance with negotiated pricing and COB processes. A strong background in health care claims is essential.

This full‑time on-site role offers comprehensive benefits and opportunities to impact patient care across New Jersey.

Qualifications

• High School Diploma or GED required.
• Three years of health care claims processing experience.
• Two years of experience with medical terminology, billing and coding.
• COB knowledge and lines of business experience preferred.

Responsibilities

• Review member medical policies and determine claim processing paths.
• Research and resolve clinical appeals and information requests.
• Coordinate clinical review processes and request information from members/providers.
• Review clinical determinations and draft related communications.
• Determine pricing for clinical claims per negotiated agreements.
• Update COB files and provider records as needed.
• Identify technical issues and escalate as appropriate.
• Respond to relevant incoming inquiries as needed.

Skills

Analytical skills

Organizational skills

Communication skills

Healthcare claims processing

Education

High School Diploma or GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a detail‑oriented Claims Specialist to review medical policies and manage clinical inquiries from members and providers.

You will coordinate clinical review, request information, and help finalize claims while ensuring compliance with negotiated pricing and COB processes. A strong background in health care claims is essential.

This full‑time on-site role offers comprehensive benefits and opportunities to impact patient care across New Jersey.