Claims Negotiation Analyst (Out of Network Mandates)

Job description

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 Role The incumbent manages the resolution of out of network billing disputes for inadvertent and/or involuntary out of network services in which Horizon BCBSNJ and the out of network health care professional cannot agree upon reimbursement. The incumbent handles the negotiation cases within the regulatory timeframes as mandated by the State and Federal regulations and be required to maintain end to end oversight to bring cases to resolution. What You'll Do Job Responsibilities: Timely and accurate creation and closure of Interactions and Intents and/or open negotiations via the SharePoint site including appropriate coding and updates related to mandate determinations and all applicable attachments for reporting purposes. Completion of eligibility verification upon assignment of new mandated cases including validation services are in scope of the surprise bill mandate, appropriate mandate applies, minimum threshold amount met, non-initiating party met all regulatory timeframes for submission submitting accurate and complete forms. Interacts with relevant parties to facilitate timely and accurate negotiation resolution. Research and review of negotiation attempts including but not limited to pulling of phone calls, authorizations, outreach to providers/billing agencies and attorneys including validation of all information submitted as part of the dispute. Updates to high dollar negotiation files including investigation and research to determine eligibility based upon on the negotiation request document. Prepares written responses including negotiation outcomes by completing a written justification on how Horizon BCBSNJ adjudicated the initial and adjusted claim, but not limited to, benefits, contracts, payment and pricing methodology, proof of plan and providing explanation of benefits within regulated timeframes. Including the handling and response for Escalated complaints from CMS/DOBI/DOL and Legal/Litigation. Accurate and timely adjustments based upon negotiation outcomes within the regulated timeframe including any applicable interest. Conducting any follow up or additional research as deemed appropriate based upon negotiation requests. Conducts detailed root cause analysis, including tracking and trending of errors and omissions that led to escalated complaints and make recommendations to avoid future occurrences. Participate in staff meetings as deemed appropriate. Creation of GSI’s and logging of cases on Blue 2 for ITS Home/Host cases requiring interaction with other Blue’s plans. Perform other duties as required by management. What You Bring Education/Experience: High School Diploma/GED required Bachelor degree preferred or relevant experience in lieu of degree Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries Experience in claims processing necessary Ability to navigate the various claims and service operations systems Healthcare industry experience helpful Knowledge: Knowledge of HBCBSNJ complaints and appeals process preferred. Knowledge of insurance claim and membership systems preferred. Knowledge of medical terminology, COB, Medicare procedures preferred. Knowledge of UCSW preferred. Knowledge of Claims Policy guidelines preferred. Knowledge of Microsoft Office Suite required. Skills and Abilities: Requires the ability to understand and use language correctly, to be determined by the Language skills test. The Employer may require an employee to pass an additional test(s) as a part of determining whether the applicant meets the minimum qualifications for the job. Requires keyboarding proficiency. 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. Requires the ability to analyze information and to understand and apply rules and procedures. Requires the ability to compose business letters. Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail member-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion. Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers. Excellent interpersonal skills (i.e. active listening). Strong research, investigative, analytical, decision making and problem solving skills. Ability to perform in high pressure situations. Ability to multitask. Ability to manage and diffuse irate callers. Time management skills. Travel (If Applicable): Some travel may be required. 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: $58,029 - $77,074 ​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: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. 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.