申诉解决分析师
Appeals Resolution Analyst
Horizon Blue Cross Blue Shield of New Jersey 帮助我们的会员实现最佳健康状态。90 多年来，我们一直是新泽西州的健康解决方案领导者，推动改善医疗质量、可负担性和会员体验的创新。我们的会员是我们的邻居、朋友和家人。正是这种理解，促使我们更好地服务并照顾那 350 万人，他们对我们充满信任。我们以拥有顶尖员工为荣，并努力营造一个创新且包容的环境，让员工能够茁壮成长。当员工发挥最佳水平并取得成功时，公司也会随之成功。
职位简介
该职位负责政府项目的初步临床申诉处理，并在监督下确保及时性指南和准确性标准得到满足。
工作内容
- 负责申诉的全流程，包括但不限于接收申诉、将数据录入医疗管理系统、协调供应商进行外部审查以及及时完成案件。
- 与提供者和会员沟通申诉流程及申诉状态。
- 回答并处理申诉热线电话队列。
- 与内部和外部供应商合作，确保申诉处理符合 NCQA、DOBI、州及其他所有监管标准。
- 根据申诉结果更新授权，并确保索赔及时处理。
- 与内部客户协作，确保他们了解申诉结果。
- 执行测试和项目以达成部门目标。
任职要求
教育/经验：
- 需要高中文凭或 GED。拥有认可大学或学院的学士学位优先。
- 希望有至少一年的急性护理、外科或康复经验。
- 希望有一年利用管理经验。
知识：
- 需要了解医疗服务体系。
- 需要了解 CPT-4 和 ICD-9 编码。
- 需要了解医学术语。
- 医疗保险经验优先。
技能和能力：
- 需要具备良好的口头和书面沟通能力。
- 需要具备良好的分析和逻辑思维能力。
- 需要使用正确的语法、用词和表达方式。4. 优先考虑打字速度达到每分钟 25 个单词。
- 有当前医疗管理系统经验优先。
为什么选择 Horizon？
在 Horizon，您将从事有意义的工作
查看英文原文
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.What You'll Do
- 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.
What You Bring
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. 4. Prefer ability to type 25 wpm.
- Experience with Current Medical Management Systems preferred
Why Horizon?
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!
Salary Range:
$44,600 - $59,745This 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:
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.
Originally posted on Himalayas