Medical Policy Analyst (Part-Time - 32 hrs weekly)

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

1d•$70,500 - $94,395

About The Position

This position is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Through analysis of medical records and claims, the individual will ensure compliance with clinical guidelines, medical policies, plan benefits and regulatory requirements.

Requirements

High School Diploma/GED required
Requires a minimum of 3 years’ clinical nursing experience
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
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

Responsibilities

Performs reviews of post service medical necessity and appealed claims for compliance with appropriate medical policy, plan benefit and correct/appropriate provide coding.
Prepares cases for Medical Director and or outside consultant review and response where appropriate.
Provides timely and accurate responses to inquiries and collaborating with the claim policy teams in relation to claims pending for medical review and appeal inquiries.
Communicates identified opportunities for development of or revisions to Horizon Medical Policies based on case review outcomes.
Manages assigned inventory, documenting production and following assignments through completion.
Stays abreast of mandates, policy and workflow changes impacting review process and outcomes.
Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization’s business and conform to these laws, regulations and policies in carrying out the accountabilities of the job.