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Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Through analysis of medical records and claims, the individual will ensure compliance with clinical guidelines, medical policies, plan benefits and regulatory requirements.What You'll Do
Performs reviews of post service medical necessity and appealed claims for compliance with appropriate medical policy, plan benefit and correct/appropriate provide coding.
Prepares cases for Medical Director and or outside consultant review and response where appropriate.
Provides timely and accurate responses to inquiries and collaborating with the claim policy teams in relation to claims pending for medical review and appeal inquiries.
Communicates identified opportunities for development of or revisions to Horizon Medical Policies based on case review outcomes.
Manages assigned inventory, documenting production and following assignments through completion.
Stays abreast of mandates, policy and workflow changes impacting review process and outcomes.
Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization’s business and conform to these laws, regulations and policies in carrying out the accountabilities of the job
What You Bring
Education/Experience:
High School Diploma/GED required
Requires a minimum of 3 years’ clinical nursing experience
Skills and Abilities:
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
Demonstrated ability to work in a production focused environment.
Proven ability to exercise sound judgment and strong problem-solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information
Why Horizon?
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range:
$70,500 - $94,395This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Disclaimer:
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.
