Appeals Resolution Analyst

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

4d•$44,600 - $59,745•Onsite

About The Position

This position is responsible for basic clinical appeals resolutions for Government Programs and, with supervision, ensuring that timeliness guidelines and accuracy standards are met.

Requirements

Requires a High School diploma or GED.
Requires knowledge of health care delivery systems.
Requires knowledge of CPT-4 and ICD-9 coding.
Requires knowledge of medical terminology.
Requires strong oral and written communication skills.
Requires strong analytical and logical thinking.
Requires use of good grammar, diction and articulation.

Nice To Haves

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.
Healthcare insurance experience preferred.
Prefer ability to type 25 wpm.
Experience with Current Medical Management Systems preferred.

Responsibilities

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.