Appeals Res Analyst I - HCS

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. 

Responsibilities:

• Perform and assess the root cause of the billing appeal and conducts thorough research of issues and determine required course of action and final deposition for Workers Compensation (WC) and Personal Injury Protection (PIP). Proactively recommend solutions and/or new processes to resolve issues and improve efficiency.

• Reconcile billing appeals and re-educates providers on established contracted rates and procedural errors to ensure accuracy of appeals and payments. Promptly escalate issues to Provider Relations Unit to avoid unnecessary appeals.

• Verify provider contracted rates to assure consistent application and compliance of SLAs and agreed payment schedule.

• Responsible for ensuring timely responses to billing appeal as required per established timelines regulated by State, contractual and HCS guidelines.

• Collaborates with the HCS billing department and provider networks to determine proper payment has been determined based on edits and state regulations.

• Liaise and advise vendor providers via telephonic inquires on billing appeals.

• Evaluates billing appeals to determine if the appeal is entered into the accurate queue within Horizon Casualty Services (HCS) propriety database, AppealTrak and KPI reporting system.

• Assists in the development of new or less experienced staff through mentoring, coaching and assisting them in the proper handling of billing appeal process.

• Other duties as assigned

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.

• In lieu of degree, 5 years of experience in field examining bills, or workers compensation industry experience required.

• Requires 2 years experience in appeals and billing or workers compensation industry experience required.

Additional licensing, certifications, registrations:

• Requires Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist from the American Health Information Management Association (AHIMA).

Knowledge:

• Requires proficiency in CPT, HCPC, ICD-9/ICD-10 coding

• Knowledge of workers compensation or Personal Injury Protection billing claims.

• Knowledge established billing guidelines

• Knowledge of Microsoft Office Suite

• Computer skills including Microsoft Word and Excel.

Skills and Abilities:

• Requires excellent verbal and communication skills

• Requires the ability to perform basic arithmetical calculations.

• Requires the ability to read, understand and interpret written materials.

• Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.

• Ability to interpret provider contracts.

• Requires the ability to analyze information and to understand and apply rules and procedures.

• Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal and external customers.

• Excellent interpersonal skills.

• Strong research, investigative, analytical and problem solving skills

• Ability to multitask

• Ability to manage and diffuse irate callers

• Time management skills

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

Salary Range:

​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

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.

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.