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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 - $70,172 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:
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.
