Policy Support Specialist

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

3d • $52,787 - $70,172

About The Position

The Policy Support Specialist reviews medical policies, prepares cases for clinical review, and tracks requests for additional information to support end-to-end resolution of clinical claims and service request or correspondence inquiries. The role researches medical records, determines appropriate claim processing or clinical review pathways, coordinates clinical reviews and appeals, and completes follow-up claim adjustments and service request closeouts. It may also involve handling relevant incoming telephone inquiries and other tasks assigned by management.

Requirements

• High school diploma or GED equivalent.
• Three years of health care claims processing experience, including researching and investigating customer inquiries.
• At least two years of experience with medical terminology, billing, and coding.
• Strong organizational and communication skills.

Nice To Haves

• Knowledge of COB and Horizon medical policies.
• Knowledge of all lines of business.
• Strong analytical and critical thinking skills.

Responsibilities

• Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business.
• Review medical policies and determine appropriate claim processing or clinical review process decisions.
• Coordinate clinical review and appeal processes, including preparing cases for clinical review and requesting additional information from members and providers.
• Review clinical determinations and initiate appropriate claim adjustments and service request closeouts, including drafting manual letters.
• Review and determine pricing for clinical claims in accordance with negotiated pricing agreements.
• Review and update Coordination of Benefit (COB) files and submit provider file updates as necessary.
• Identify technical issues and submit them to the appropriate area for resolution.
• Handle relevant incoming telephone inquiries, as needed.
• Perform other tasks as assigned by management.

Benefits

• Comprehensive health benefits, including medical, dental, and vision.
• Retirement plans.
• Generous paid time off.
• Incentive plans.
• Wellness programs.
• Paid volunteer time off.
• Tuition reimbursement.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED