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.
Skills Required
- High school diploma or GED
- Bachelor's degree from an accredited college or university
- One year of recent acute care medical-surgical or rehabilitation experience
- One year of utilization management experience
- Knowledge of healthcare delivery systems
- Knowledge of CPT-4 and ICD-9 coding
- Knowledge of medical terminology
- Strong oral and written communication skills
- Strong analytical and logical thinking
- Good grammar, diction, and articulation
- Ability to type 25 words per minute
- Healthcare insurance experience
- Experience with current medical management systems
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.
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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.
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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.
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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
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.
