[Hiring] Policy Support Specialist @Horizon Blue Cross Blue Shield of New Jersey

Role Description

Responsible for reviewing medical policies, preparing cases for clinical review, and tracking additional information requests for end to end resolution of clinical claims and service request/correspondence inquiries.

What You'll Do

• Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business.
• Review medical policies and determine the appropriate claim processing or clinical review process decisions.
• Coordinate the clinical review and appeal processes including preparing cases for clinical review and requesting additional information from members and providers.
• Review clinical determinations and initiate appropriate claim adjustments and service requests closeout, including drafting manual letters.
• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements.
• Review and update Coordination of Benefit (COB) files and submit provider file updates as necessary.
• Identify technical issues and submit to the appropriate area for resolution.
• May handle relevant incoming telephone inquiries.
• May perform other tasks as assigned by management.

Qualifications

• Minimum of a High School Diploma or GED equivalent required.
• Requires three (3) years of health care claims processing experience including researching and investigating customer inquiries.
• Requires a minimum of two (2) years of experience with medical terminology, billing and coding.
• Knowledge of COB and Horizon medical policies preferred.
• Knowledge of all lines of business preferred.

Requirements

• Strong analytical and critical thinking skills preferred.
• Strong organizational and communication skills.

Benefits

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement