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 handling all Utilization Management medical appeal cases. Ensures that timeliness guidelines are met and appeal handled in compliance with regulatory requirements of various agencies including but not limited to NCQA,URAC and NJ/Federal regulations. Provides mentoring and clinical liaison support to appeals staff. Performs special projects as assigned by managementWhat You'll Do
Assesses patient's clinical need against established guidelines and standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.
Evaluates the necessity, appropriateness and efficiency of medical services and procedures by inpatient facilities.
Performs review of medical records and prepares medical records for review by Medical Director as appropriate.
Investigates and resolves complicated appeals, coordinating with legal department as necessary and handles appeals concerning pre existing conditions.
Investigates and resolves high priority cases involving DOBI and Executive inquiries.
Prepares and presents appeals to Appeals Committee in accordance with criteria including coordination with independent URO.
Conducts presentations of appeals process to internal customers and works with Delegate and Vendor Oversight to assist vendors in establishing procedures to ensure their appeals process complies with requirements.
Plans appropriate allocation of resources to provide quality patient care in the most cost effective manner.
Documents accurately and comprehensively based on the standards of practice and current organization policies.
Interacts and communicates with facilities, physicians and or members/families, either telephonically and or on site striving for continuity and efficiency as the member is managed along the continuum of care.
Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Facilitates the external review process with the IURO and IRO.
Provides 24/7 on call appeal support as scheduled.
Actively participates in enterprise meetings as management-s proxy as necessary.
Performs special projects as assigned by management.
Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.
What You Bring
Education/Experience:
High School Diploma/GED required.
Bachelor degree in health care management preferred or relevant experience in lieu of degree.
Requires 2 years clinical experience.
Requires 3 years experience in the health care delivery system/industry.
Additional licensing, certifications, registrations:
Requires a Registered Nurse License.
Knowledge:
Specialized knowledge/skills: Requires working knowledge of principles of utilization management.
Requires knowledge of health care contracts and benefit eligibility requirements.
Requires knowledge of hospital structures and payment systems.
Requires excellent oral and written communication skills.
Requires the ability to work in a high volume environment with moderate supervision.
Require the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.
Skills & Abilities:
Requires the ability to utilize a personal computer and applicable software.
Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Demonstrated ability to deliver highly technical information to less technical individuals.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.
Proven ability to exercise sound judgment and strong problem solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be client service focused with effective ability to empathize.
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:
$79,100 - $105,945This 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.
Skills Required
- High school diploma or GED
- Bachelor's degree in healthcare management or relevant equivalent experience
- Two years of clinical experience
- Three years of experience in the healthcare delivery system or healthcare industry
- Current Registered Nurse license
- Working knowledge of utilization management principles
- Knowledge of healthcare contracts and benefit eligibility requirements
- Knowledge of hospital structures and payment systems
- Excellent oral and written communication skills
- Ability to work in a high-volume environment with moderate supervision
- Strong negotiation, persuasion, and problem-solving skills
- Ability to manage multiple priorities and deliver timely, accurate work
Horizon Blue Cross Blue Shield of New Jersey Compensation & Benefits Highlights
The following summarizes recurring compensation and benefits themes identified from responses generated by popular LLMs to common candidate questions about Horizon Blue Cross Blue Shield of New Jersey and has not been reviewed or approved by Horizon Blue Cross Blue Shield of New Jersey.
-
Leave & Time Off Breadth — PTO is characterized as generous, with ample days off and holidays enhancing the overall package. This breadth of time away supports a favorable view of total rewards.
-
Flexible Benefits — Remote and hybrid options are available in multiple functions and are cited as a meaningful perk. Flexibility in where work is performed contributes to overall satisfaction with rewards.
-
Retirement Support — The 401(k) match is considered decent to good. Retirement offerings are viewed as a solid component of the total package.
Horizon Blue Cross Blue Shield of New Jersey Insights
Similar Jobs
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.
