[Hiring] Out of Network Mandate Arbitration Analyst @Horizon Blue Cross Blue Shield of New Jersey

Role Description

The Out of Network (OON) Mandate Arbitration Analyst will be responsible for researching, investigating and coordinating document collections as well as preparing a summary of information related to Executive/Regulatory complaints, litigation, legal requests and other inquiries received related to the No Surprises Act (NSA). The OON Mandate Analyst will need to work with a variety of internal departments to prepare fulsome analysis for the assigned Paralegal (including outside counsel) and Executive/Regulatory team members.

What You'll Do

• Prepare factual investigation files and research summary including root cause summary analysis as outlined on Litigation Document, Subpoena Request, Administrative Law Case Request, Commission Appeals/2nd Level Administrative appeals and NSA files (and/or other outside agency research request).
• Analyze data including but not limited to claim charts, medical authorizations, call records, provider requests, appeals, complaints, correspondence and other documents related to the requested case.
• Summarize a justification for the legal, Exec/Reg, or other department regarding Horizon's claim handling, including but not limited to member benefits, contracts, payment methodology, mandate policies and procedures.
• Provide reports as needed for the case. May include requests for informatics reports.
• Search and review all phone calls related to the case and summarize findings.
• Request and provide copies of relevant documents, including but not limited to: Summary Plan Documents and Contracts, NSA negotiation and/or arbitration documents.
• Review contracts for appropriate application of benefits/mandates.
• Assess cause of complaint/appeal/legal case and determine the root cause of errors. Share root cause with the appropriate Service Teams for re-education.
• Recommend actions to the legal department on LDR cases based on case file review.
• Attend Deposition Hearings, Administrative Law Hearings, Commission Meetings and other outside Committee meetings requiring subject matter expertise.

Qualifications

• High School Diploma/GED required.
• Seven years of business experience which must include 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
• In lieu of seven years of experience, Bachelor's and 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries is acceptable.
• Healthcare industry experience required.
• Experience in complex claims processing necessary.
• Prior OON Mandate, Complaint/appeals handling experience preferred.
• Ability to navigate various claims and service operations systems to obtain the necessary case information.

Requirements

• Knowledge of OON State and Federal Mandates required.
• Knowledge of HBCBSNJ complaints and appeals process preferred.
• Knowledge of insurance claim and membership systems required.
• Knowledge of medical terminology, COB, Medicare procedures required.
• Knowledge of NCompass and Nasco required.
• Knowledge of Claims Policy guidelines required.
• Proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook).

Skills and Abilities

• Ability to understand and use language correctly.
• Ability to read, understand and interpret written materials.
• Ability to analyze information and to understand and apply rules and procedures.
• Strong verbal and written communication skills.
• Detail-oriented in developing individual correspondence for each case.
• Excellent interpersonal skills (i.e. active listening).
• Strong research, investigative, analytical and problem-solving skills.
• Ability to handle confidential, proprietary, and privileged information with total discretion.
• Ability to multitask.
• Time management skills.

Travel

• Some travel may be required.

Benefits

• 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.