Admin Appeals Analyst II

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.

• Performs and assess root cause(s) of appeal, conducts thorough research of issue(s), determines required course of action and final disposition focusing on more complex appeals.

• Interacts with relevant parties to facilitate timely and accurate appeal resolution.

• Assist claim appeals analysts with complicated appeals when needed.

• Train newly hired staff on claim appeals research, analysis and resolution.

• Prepare monthly claim appeal activity reports.

• Conducts claim appeals departmental overview for internal departments.

• Assist Manager with conducting annual claim appeal audits on delegates and vendors to verify accuracy of information related to appeals.

• Develops customized, timely, accurate and detailed correspondence for delivery to relevant party(ies) of resolution.

• Responds to regulatory entity or members/providers in writing, regarding issue details and final determination to close the appeal. Each response must be customized to the specific situation and address all issues presented by the provider.

• Partners with internal departments to review and finalize appeal determinations that have escalated from litigations, or the Department of Banking and Insurance and other internal departments.

• May prepare materials for and may attend meetings on behalf of the manager/supervisor to discuss the appeals processes, or specific appeals trends and root causes.

• High School Diploma/GED required.

• Requires five years of healthcare experience which must include at least one year of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.

• Experience in claims processing helpful.

• Ability to navigate the various claims and service operations systems.

• Healthcare industry experience helpful.

• Knowledge of Medicare operations Appeals process preferred.

• Knowledge of insurance claim and membership systems preferred.

• Knowledge of claim billing forms required.

• Knowledge of medical terminology, Coordination of Benefits and Third Party Liability rules required.

• Knowledge of Facets Claims Processing, Provider Set-ups and Member Eligibility preferred.

• Knowledge of Claims policy guidelines preferred.

• Knowledge of Microsoft Office Suite (including but not limited to Outlook, Word and Excel) required.

• Knowledge of HIPAA requirements.

• Knowledge of CPT Coding preferred.

• Knowledge of Diagnosis Coding preferred.

• Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail provider-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion.

• Strong research, investigative, analytical, decision making and problem solving skills.

• Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers.

• Requires the ability to analyze information and to understand and apply rules and procedures.

• Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.

• Requires claims experience.

• Time management skills.

• Ability to multitask.

• Some travel may be required.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

This 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:
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.