Health Policy Analyst

Horizon Medical Policy SpecialistHorizon 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 is responsible for the medical policy determination of claims/cases consistent with Plan Medical Policy to ensure appropriate and efficient utilization of benefits. Through analysis of medical records and claims, the individual will ensure compliance with clinical guidelines, medical policies, plan benefits and regulatory requirements.What You'll DoPerforms reviews of post service medical necessity and appealed claims for compliance with appropriate medical policy, plan benefit and correct/appropriate provide coding.Prepares cases for Medical Director and or outside consultant review and response where appropriate.Provides timely and accurate responses to inquiries and collaborating with the claim policy teams in relation to claims pending for medical review and appeal inquiries.Communicates identified opportunities for development of or revisions to Horizon Medical Policies based on case review outcomes.Manages assigned inventory, documenting production and following assignments through completion.Stays abreast of mandates, policy and workflow changes impacting review process and outcomes.Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization's business and conform to these laws, regulations and policies in carrying out the accountabilities of the jobWhat You BringEducation/Experience: High School Diploma/GED required Requires a minimum of 3 years' clinical nursing experienceSkills and Abilities: Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment. Proven ability to exercise sound judgment and strong problem-solving skills. Proven ability to ask probing questions and obtain thorough and relevant informationWhy 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: $70,500 - $94,395This 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 ReimbursementHorizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.