Strategic Appeals Analyst

Horizon Blue Cross Blue Shield of New Jersey; United States; Remote; USD 63,000 - 84,000; Full time

Benefits offered by this job

Health benefits

Retirement plan

Paid PTO

Incentive plans

Wellness program

Volunteer time off

Tuition reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey seeks an appeals analyst to manage end-to-end complaint and appeal cases, conduct investigations, ensure regulatory compliance, and prepare comprehensive case files for leadership, CMS/State entities, and Administrative Law Judges.

The role coordinates with internal and external stakeholders to deliver timely, accurate resolutions and supports Medicaid/Medicare compliance while focusing on member experience.

Responsibilities

• Prepare comprehensive appeal files and present cases to the Leadership Appeals Workgroup and external reviewers, ensuring documentation is complete and organized.
• Investigate and analyze member/provider complaints and appeals by gathering documentation, interviewing stakeholders, and reviewing history to validate accuracy and compliance.
• Apply critical thinking to determine root causes, draft clear written determinations within turnaround times, and communicate professionally to stakeholders.
• Coordinate with Legal, Compliance and Regulatory Affairs for escalated cases and potential testimony.

Job description

Horizon Blue Cross Blue Shield of New Jersey seeks an appeals analyst to manage end-to-end complaint and appeal cases, conduct investigations, ensure regulatory compliance, and prepare comprehensive case files for leadership, CMS/State entities, and Administrative Law Judges.

The role coordinates with internal and external stakeholders to deliver timely, accurate resolutions and supports Medicaid/Medicare compliance while focusing on member experience.