Remote Appeals Analyst - Health Insurance Compliance

Horizon Blue Cross Blue Shield; Newark (NJ); Hybrid; USD 63,000 - 84,000; Full time

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an Appeals Analyst to manage end-to-end complaint and appeal cases, conduct investigations, and ensure regulatory and policy compliance. You will prepare comprehensive case files, coordinate with internal teams and external reviewers, and support Medicaid and Medicare compliance while aiming for timely, accurate resolutions.

The role requires strong analytical thinking, attention to detail, and clear written and verbal communication to

Qualifications

• Four+ years of correspondence and/or telephone customer service experience.
• Experience in health insurance, claims appeals and grievances preferred.
• Experience in complex claims processing required.
• Knowledge of Medicare/Medicaid regulations and guidelines.

Responsibilities

• 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 from documentation and calls.
• Apply critical thinking to determine root cause and draft written determinations within required turnaround times.
• Validate medical claims against EOC/State Medicaid contracts to ensure proper coverage and adjudication.
• Support regulatory review with Legal and Compliance when escalated cases require it.

Skills

Communication skills

Quantitative reasoning

Time management

De-escalation techniques

Education

High School Diploma/GED

Bachelor’s degree preferred

Tools

Microsoft Office Suite

NCOMPASS CRM

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an Appeals Analyst to manage end-to-end complaint and appeal cases, conduct investigations, and ensure regulatory and policy compliance. You will prepare comprehensive case files, coordinate with internal teams and external reviewers, and support Medicaid and Medicare compliance while aiming for timely, accurate resolutions.

The role requires strong analytical thinking, attention to detail, and clear written and verbal communication to