Remote Appeals Analyst I - Investigations & Compliance

Horizon Blue Cross Blue Shield; New Jersey; Remote; 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 is seeking an GP Appeals Analyst I in Hopewell, NJ. The role focuses on end-to-end complaint and appeal handling, thorough investigations, and defensible decisions within regulatory guidelines, with collaboration across Legal, Compliance, and Regulatory Affairs.

You will prepare case files for leadership and CMS/State review, track documentation, and analyze trends to drive quality improvements and enhance member experience.

Qualifications

• High School Diploma or GED required; Bachelor's degree preferred or commensurate experience.
• Experience in health insurance, claim appeals, and grievances is preferred.
• Experience in complex claims processing and handling grievances or appeals is desirable.

Responsibilities

• Prepare comprehensive appeal files and present cases to leadership and external reviewers.
• Investigate member/provider complaints by gathering docs and reviewing benefit, billing, and service issues.
• Apply critical thinking to determine root causes and draft clear written determinations within turnaround times.
• Coordinate with Legal, Compliance and Regulatory Affairs for escalated cases and potential ALJ hearings.
• Validate medical claims against Evidence of Coverage and contract terms to ensure proper adjudication.
• Perform root cause analysis to identify trends and drive process improvements.
• Present cases to leadership and participate in hearings as needed.

Skills

Keyboarding proficiency

Communication skills

Analytical thinking

Time management

De-escalation techniques

Education

High School Diploma/GED

Bachelor degree preferred or relevant experience

Tools

Microsoft Office Suite

NCOMPASS CRM

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an GP Appeals Analyst I in Hopewell, NJ. The role focuses on end-to-end complaint and appeal handling, thorough investigations, and defensible decisions within regulatory guidelines, with collaboration across Legal, Compliance, and Regulatory Affairs.

You will prepare case files for leadership and CMS/State review, track documentation, and analyze trends to drive quality improvements and enhance member experience.