Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware
Job Summary:
Review medical documentation to achieve results in accurate clinical determination based upon scope of practice.
Responsibilities:
- Reviewing professional medical claims policy related issues or claims in pending status.
- Make determinations based on clinical reviews, along with federal, state and company guidelines.
- Prepare cases for external and internal review.
- Provision of timely and accurate responses to inquiries from the Claim Policy teams in relation to courtesy
- Pre-determined requests, claims pending for medical review, and appeals inquiries.
- Routing determinations to appropriate area.
- Partner with claims policy analysts in order to assure accurate claims adjudication.
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.
Experience/Education:
- High School Diploma or GED required. Prefers a BSN, requires a NJ State Registered Nurse License or MD including non board certified, but certified abroad.
- Prefers a minimum of 3 years clinical experience.
- Prefers a minimum of 3 years business/insurance experience.
Additional licensing, certifications, registrations:
- Prefer certification in medical coding.
Knowledge/Skills:
- Prefer knowledge of Horizon product lines.
- Prefer knowledge of Workman's Compensation, Medicare, COB, no fault.
- Require strong knowledge of Microsoft Office Products.
- Team Player, Strong Analytical, good Written and Verbal Communication Skills, Interpersonal Skills.
Salary Range:
$69,500 - $93,030
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:
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Comprehensive health benefits (Medical/Dental/Vision)
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Retirement Plans
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Generous PTO
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Incentive Plans
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Wellness Programs
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Paid Volunteer Time Off
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Tuition Reimbursement
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.
What We Do
Horizon Blue Cross Blue Shield of New Jersey- the state’s largest and oldest health insurer - is a subsidiary of Horizon Mutual Holdings, Inc., a not-for-profit mutual holding company.
Together with its affiliates, Horizon provides a wide array of medical, dental, vision and prescription insurance products and services. As New Jersey’ health solutions leader, Horizon is transforming healthcare by working with doctors and hospitals to deliver innovative, patient-centered programs that improve quality and lower costs. It is headquartered in Newark, NJ with offices in Wall and Hopewell, NJ.
Horizon serves 3.7 million members including more than 1 million who rely on Medicaid for their health coverage.
