OON Mandate Arbitration Analyst

Horizon Healthcare Services•Newark, NJ

17h

About The Position

The Out of Network (OON) Mandate Arbitration Analyst will be responsible for researching, investigating and coordinating of document collections as well as preparing a summary of information related to Executive/Regulatory complaints, litigation, legal requests and other inquiries received related to the No Surprises Act (NSA). The OON Mandate Analyst will need to work with a variety of internal departments to prepare fulsome analysis for the assigned Paralegal (including outside counsel) and Executive/Regulatory team members.

Requirements

High School Diploma/GED required
Requires seven years of business experience which must include 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
In lieu of seven years of experience, Bachelor's and 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries is acceptable.
Healthcare industry experience required.
Experience in complex claims processing necessary.
Knowledge of OON State and Federal Mandates required
Knowledge of HBCBSNJ complaints and appeals process preferred
Knowledge of insurance claim and membership systems required
Knowledge of medical terminology, COB, Medicare procedures required
Knowledge of NCompass and Nasco required
Knowledge of Claims Policy guidelines required
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products, (Word, Excel, PowerPoint and Outlook).
Requires the ability to understand and use language correctly
Requires the ability to read, understand and interpret written materials.
Requires the ability to analyze information and to understand and apply rules and procedures
Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder
Must be able to detail member/provider-specific issues through the development of individual correspondence for each case explaining all issues in a comprehensive, understandable fashion
Excellent interpersonal skills (i.e. active listening)
Strong research, investigative, analytical and problem solving skills
Requires the ability to handle confidential, proprietary, and privileged information with total discretion.
Ability to multitask
Time management skills

Nice To Haves

Prior OON Mandate, Complaint/appeals handling experience preferred.

Responsibilities

Prepare factual investigation files and research summary including root cause summary analysis as outlined on Litigation Document, Subpoena Request, Administrative Law Case Request, Commission Appeals/2nd Level Administrative appeals and NSA files (and/or other outside agency research request).
Analysis of data including but not limited to claim charts, medical authorizations, call records, provider requests, appeals, complaints, correspondence and other documents related to the requested case.
Summarize a justification for the legal, Exec/Reg, or other department regarding Horizon's claim handling, including but not limited to member benefits, contracts, payment methodology, mandate policies and procedures.
Provide reports as needed for the case. May include requests for informatics reports.
Search and review all phone calls (listening to each to determine how the call was handled) related to the case and summarize findings.
Request and provide copies of relevant documents, including but not limited to: Summary Plan Documents and Contracts, NSA negotiation and/or arbitration documents.
Review contracts for appropriate application of benefits/mandates.
Assess cause of complaint/appeal/legal case and determines the root cause of errors. Shares root cause with the appropriate Service Teams for re-education.
Recommends actions to the legal department on LDR cases based on case file review, i.e., overturn a denial due to an authorization that was on file, or claim payment that was not made correctly.
Other duties as assigned or needed by the Legal Department, by the Commission, Department of Banking and Insurance and/or another agency.
Attendance at Deposition Hearings, Administrative Law Hearings, Commission Meetings and other outside Committee meetings requiring subject matter expertise by the preparer of the files.