Appeals Resolution Analyst

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 basic clinical appeals resolutions for Government Programs and, with supervision, ensuring that timeliness guidelines and accuracy standards are met.

Responsibilities

• Responsible for the end to end process for appeals, including but not limited to the receipt of appeals, data entry into medical management system, facilitating external review by vendors, and timely case completion.
• Speak to providers and members regarding the appeal process, as well as status of appeals.
• Answer and triage the appeal Hotline phone queue.
• Collaborate with both internal and external vendors to ensure that appeals are processed maintaining NCQA, DOBI, State and all other regulatory standards.
• Update authorizations based on outcome of appeals and ensure that claims are effectuated timely.
• Collaborate with internal customers to ensure that they are notified of the Appeal outcome.
• Perform testing and projects to meet departmental goals.

Education/Experience

• Requires a High School diploma or GED.
• Bachelor's degree from an accredited college or university preferred.
• Prefer a minimum of one (1) year recent acute care medical-surgical or rehabilitation experience.
• Prefer one (1) year utilization management experience.

Knowledge

• Requires knowledge of health care delivery systems.
• Requires knowledge of CPT-4 and ICD-9 coding.
• Requires knowledge of medical terminology.
• Healthcare insurance experience preferred.

Skills and Abilities

• Requires strong oral and written communication skills.
• Requires strong analytical and logical thinking.
• Requires use of good grammar, diction and articulation.
• Prefer ability to type 25 wpm.
• Experience with Current Medical Management Systems preferred.

Benefits

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!

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

Pay

Salary Range $44,600 - $59,745. 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.