UM Appeals Analyst - MAC

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.About the RoleThis position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators. The incumbent prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings. Incumbent will mentor more junior staff by responding to questions and sharing expertise. Incumbent will adhere to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows.What You'll DoResponsibilities:Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives via incoming calls or correspondence based on workflows.Manage correspondence of toll-free UM Appeal hotline and UM Appeal fax server. This includes speaking with various customers, education, triaging calls, and disseminating information during business hours. In addition, calls to the appellant, education, triaging incoming faxes, and assigning appeals during business hours.Interacts with and supports Medical Directors. Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors. Prepare, document and route cases in appropriate system for clinical review.Prepares, presents, and schedules cases for the Member Appeals Committee (MAC) Committee & Expedited Subcommittees. Responsible for the comprehensive explanation of previous denials, the scope of coverage, applied criteria, and how the case was handled. Responsible for addressing questions posed by the appellant or committee and administrative support of completing the appeals process.Responsible for partnering with all parties that handled the case to facilitate fact gathering and to gain a thorough understanding of the determination and appropriate benefits. Conducts and provides root cause analysis to avoid future appeal occurrences. Works with supervisor to develop and deliver refresher training to business teams on proper appeal referral, handling, and MAC case preparation.Assists in the development of junior staff through mentoring, coaching and assisting them in the proper handling of appeal cases. Act as a mentor to junior staff by responding to questions and sharing expertise.Assists with running and validating reports for the team.Perform other relevant tasks as assigned by Management.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.What You BringEducation/Experience:High School Diploma/GED required.Requires minimum of 5 years healthcare industry or operations experience.Requires minimum 3 years direct customer service experience, preferably in a medical support related position.Prefer experience with prior appeals handling and correspondence.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 medical terminology.Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius.Prefer knowledge of contracts, enrollment, billing, & claims coding/processing.Prefer knowledge of Managed Care principles.Skills and Abilities:Requires strong oral and written communication skills.Requires ability to make sound decisions under the direction of the supervisor.Prefer the ability to analyze and resolve problems with minimal supervision.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 Microsoft Outlook).Why Horizon?At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!Salary Range:$63,000 - $84,420This 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 PlansGenerous PTOIncentive PlansWellness ProgramsPaid Volunteer Time OffTuition ReimbursementDisclaimer:Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.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. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr Horizon-Blue-Cross-Blue-Shield-of-New-Jersey