Policy Support Specialist
纽约州的蓝十字绿盾赋予我们的成员能力，以达到他们最好的健康.90多年来，我们一直是新泽西州的卫生解决方案领导者，推动了改善医疗保健质量，可负担性和会员体验的创新。我们的成员是我们的邻居，朋友和家庭。这就是这种理解驱使我们更好地为信任我们的人群服务和照顾3.5百万人。我们自豪的是我们在班级中最优秀的员工，并努力保持一个让他们壮成长的创新的和包容环境。当我们的员工尽最大努力成功时，公司就会取得成功。关于角色 负责审查医疗政策，准备病例进行临床审核，并跟踪对临床要求/服务请求/通信查询的终端解决额外信息请求。你将做什么？责任：· 研究成员医疗记录来解决所有业务领域的临床修订未完成的索赔或服务请求。·审查医疗策略，确定适当的申请处理或临床审计过程决策。·协调临床审批和上诉流程包括；为临床审理做好案件的准备以及向成员和提供商寻求额外信息。· 审查临床确定性，并启动适当的索赔调整和服务请求完成，包括编写手册信件。· 根据谈判定价协议对临床索赔进行评估和定价。· 审查和更新福利协调 (COB) 文件，并在必要时提交供应商档案更新。· 识别技术问题，并提交到适合解决领域。· 可以处理相关的电话查询。·可以执行管理部门所指定的其他任务。你带来什么教育和资格：· 最少需要高中文凭或 GED 等级。·需要三 (3) 年的医疗保健索赔处理经验，包括对客户询问进行研究和调查。·要求至少两 (2) 年的医学术语，账单和编码经验。·优先了解 COB 和 Horizon 医疗政策。·优先熟悉所有行业领域。技能：·强大的分析和批判性思维能力；•强大的组织和沟通技巧为什么？在 Horizon,你将做直接影响到有意义的工作。
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
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
Responsibilities:
- 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.
What You Bring
Education & 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.
Skills:
- Strong analytical and critical thinking skills preferred.
- Strong organizational and communication skills
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:
$52,787 - $70,172This 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. 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