GP Appeals Analyst I

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

19h•$63,000 - $84,420•Onsite

About The Position

The incumbent manages end‑to‑end complaint and appeal cases, conducting thorough investigations, ensuring regulatory and policy compliance, and documenting clear, defensible decisions. The role coordinates with internal and external stakeholders to deliver timely, accurate resolutions, partners with State agencies and Departments of Banking and Insurance as needed and supports Medicaid and Medicare compliance including awareness of impacts to Medicare STARS performance. The Analyst prepares comprehensive case files for review by leadership, CMS/State entities, and Administrative Law Judges, maintains detailed tracking and documentation, and analyzes trends to drive quality improvement and enhance the member experience.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree.
Must include four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
Experience in health insurance, claim appeals and grievances preferred.
Experience in complex claims processing necessary.
Prior grievances and appeals handling experience preferred.
Knowledge of insurance claim and membership systems required.
Knowledge of claim processes, benefits, and claim policy guidelines.
Knowledge of medical terminology, COB, Medicare procedures required.
In depth knowledge of Claims Policy guidelines required.
Strong knowledge of Microsoft Office Suite required.
Requires keyboarding proficiency.
Demonstrates strong language proficiency and clear, effective communication.
Applies quantitative reasoning to perform accurate calculations and interpret numerical data.
Reads and interprets complex written materials to extract key information.
Uses sound judgment to choose appropriate analytical or mathematical methods to solve problems.
Analyzes information and applies relevant rules, policies, and procedures.
Produces professional business correspondence conveying complex information clearly.
Communicates technical details in an accessible way to internal leaders and external stakeholders; prepares tailored, comprehensive case‑specific correspondence.
Demonstrates strong interpersonal skills, including active listening.
Performs thorough research and uses analytical and problem‑solving skills to resolve issues.
Manages multiple priorities effectively.
Uses de‑escalation techniques to handle difficult or irate callers.
Demonstrates effective time‑management skills.

Nice To Haves

Knowledge of HBCBSNJ complaints and appeals process preferred.
Knowledge of NCOMPASS or other Customer Relationship Management System preferred.

Responsibilities

Prepare comprehensive appeal files and present cases to the Leadership Appeals Workgroup; coordinate submission to independent external reviewers (IRE) and Administrative Law Judge (ALJ) as needed, ensuring exhibits include claim records, authorizations, research summary, evidence of coverage, timelines, and documentation are complete, accurate, and well-organized. Provides clear, comprehensive explanations of denial decisions, benefit coverage, and case handling.
Investigate and analyze member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history to validate accuracy, ensure proper configuration and adjudication, and confirm case completeness and compliance with all regulatory, contractual, and organizational requirements.
Apply critical thinking to determine root cause, validate findings, and recommend appropriate resolutions or corrective actions, while drafting clear, accurate written determinations and correspondence within required turnaround times to ensure messaging is professional and customer-friendly.
Prepare comprehensive appeal files to be presented to Leadership Appeals Workgroup and for submission to independent external reviewers (IRE), ensuring files include all relevant documentation, claim charts, medical records, Evidence of Coverage, and other Plan documents.
Search and review all phone calls (listening to each to determine how the call was handled) related to the case and summarize findings.
Consults with Legal, Compliance and Regulatory Affairs when escalated cases require regulatory review or litigation; may testify on behalf of the organization.
Validate medical claims by cross-referencing the member’s Evidence of Coverage (EOC) or State Medicaid contract with benefit configuration/coding to confirm services are correctly covered and adjudicated.
Performs detailed root cause analysis to identify trends, errors, and systemic issues contributing to escalated complaints, then recommends corrective actions and process improvements to prevent future appeals and reduce administrative exceptions.
Coordinates with all involved business areas to gather facts and ensure a full understanding of the applicable benefit contract.
Authorizes administrative exceptions, including claim adjustments at higher thresholds, to resolve appeals appropriately.
Presents cases before the Leadership Appeals Workgroup (Braven senior leadership, medical directors, and other stakeholders) and attend Administrative Law hearings, partnering with Legal, to defend appeals before an Administrative Law Judge (ALJ) as needed, ensuring exhibits, timelines, and documentation are complete, accurate, and well-organized.
Performs other duties as assigned.