GP Appeals Analyst I

Job not on LinkedIn

🔥 2 minutes ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $63k - $84.4k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 13%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• Manage end-to-end complaint and appeal cases • Investigate member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history • Prepare comprehensive appeal files for Leadership Appeals Workgroup, independent external reviewers, and Administrative Law Judges • Coordinate submission to independent external reviewers and Administrative Law Judges as needed • Present clear explanations of denial decisions, benefit coverage, and case handling • Apply critical thinking and root-cause analysis to determine findings and recommend resolutions or corrective actions • Draft accurate, professional, customer-friendly written determinations and correspondence within required turnaround times • Search, review, and summarize phone calls related to cases • Consult with Legal, Compliance, and Regulatory Affairs on escalated cases; may testify on behalf of the organization • Validate medical claims against Evidence of Coverage or State Medicaid contracts, benefit configuration, and coding • Identify trends, errors, and systemic issues and recommend process improvements • Coordinate with business areas to gather facts and understand applicable benefit contracts • Authorize administrative exceptions, including higher-threshold claim adjustments • Present cases before the Leadership Appeals Workgroup and attend Administrative Law hearings • Maintain detailed case tracking and documentation • Perform other duties as assigned

🎯 Requirements

• High School Diploma/GED required • Bachelor degree preferred or relevant experience in lieu of degree • Four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries • Experience in health insurance, claim appeals and grievances preferred • Experience in complex claims processing necessary • Prior grievances and appeals handling experience preferred • Knowledge of insurance claim and membership systems required • Knowledge of claim processes, benefits, and claim policy guidelines • Knowledge of medical terminology, COB, Medicare procedures required • Knowledge of Medicare/Medicaid regulations and guidelines • In depth knowledge of Claims Policy guidelines required • Strong knowledge of Microsoft Office Suite required • Keyboarding proficiency • Strong language proficiency and clear, effective communication • Quantitative reasoning and numerical data interpretation • Ability to read and interpret complex written materials • Analytical, mathematical, research, problem-solving, and judgment skills • Ability to produce professional business correspondence conveying complex information clearly • Strong interpersonal skills, including active listening • Ability to manage multiple priorities effectively • De-escalation skills for difficult or irate callers • Effective time-management skills • May be required to pass employment qualification test(s) • Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

🏖️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement • Remote work arrangement • Some travel may be required