Policy Support Specialist

Horizon Healthcare Services • Hopewell, NJ

2d

About The Position

The Policy Support Specialist reviews medical policies, prepares cases for clinical review, and tracks additional information requests 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 paths, coordinates clinical reviews and appeals, and takes follow-up actions based on clinical determinations. It also supports claim pricing, Coordination of Benefits file maintenance, technical issue resolution, and may respond to relevant telephone inquiries.

Requirements

• High school diploma or GED equivalent required.
• 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 analytical and critical thinking skills preferred.
• Strong organizational and communication skills.

Nice To Haves

• Knowledge of COB and Horizon medical policies.
• Knowledge of all lines of business.

Responsibilities

• Research member medical records to resolve claims or service requests that pend with clinical edits across all lines of business.
• Review medical policies and determine appropriate claim processing or clinical review 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 closeout, 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.
• May handle relevant incoming telephone inquiries.
• May perform other tasks as assigned by management.

Benefits

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

What This Job Offers

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