Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Job Summary:

This position is responsible for the efficient functioning of the appeals resolution correspondence unit, which handles the clinical appeals resolutions, ensuring that timeliness guidelines and accuracy standards are met.Responsibilities:

• Input and update demographic customer and clinical data for all utilization management programs and Continued Stay Review identifying eligibility via telephone and CRT prior to utilization.

• Contribute to the maintenance of a competent staff by assisting with training new Analysts and Review Specialists etc. and assisting with monitoring post training performance to assure high quality performance.

• Act as a resource for the Review Specialist providing appropriate guidance and coaching.

• Compile and tabulate specific data on utilization management programs to monitor activity and make recommendations as needed.

• Monitor the phone queue and make appropriate personnel adjustments to ensure that phone metrics are met.

• Monitor queues to ensure that the Appeals are processed maintaining NCQA, State and DOBI requirements.

• Monitor timeliness of appeal resolution and make appropriate daily assignment changes.

• Assist in the completion of mandatory reporting inclusive of both internal and external reporting needs.

• Assist in the development and implementation of workflows specific to the Appeals department.

• Assist in performing staff audits as well as silent auditing of the phone queue.

• Serve as the liaison for Medicaid Fair Hearings and ensuring compliance with continuation of benefits during the appeals process (Government Programs only).

• Assist in the completion of Delegate Vendor Audits. The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.

Disclaimer:

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Education/Experience:

• High School Diploma/GED required.

• Requires a minimum of two (2) years utilization management or appeals experience.

• This position is required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department's business needs.

Knowledge:

• Requires knowledge of health care delivery systems.

• Requires knowledge of community resources.

• Requires knowledge of CPT-4 and ICD-9 coding

• Requires knowledge of current Medical Management system

Skills and Abilities:

• Requires strong oral and written communication skills.

• Requires strong analytical and logical thinking.

• Requires use of good grammar, diction and articulation.

• Prefer ability to type 25 wpm.

Salary Range:

$48,600 - $65,100

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.