Appeals Analyst- GP

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.

The incumbent manages end‑to‑end complaint and appeal cases, conducting thorough investigations, ensuring regulatory and policy compliance, and documenting clear, defensible decisions. The role coordinates with internal and external stakeholders to deliver timely, accurate resolutions, partners with State agencies and Departments of Banking and Insurance as needed and supports Medicaid and Medicare compliance including awareness of impacts to Medicare STARS performance. The Analyst prepares comprehensive case files for review by leadership, CMS/State entities, and Administrative Law Judges, maintains detailed tracking and documentation, and analyzes trends to drive quality improvement and enhance the member experience.

• Prepare comprehensive appeal files and present cases to the Leadership Appeals Workgroup; coordinate submission to independent external reviewers (IRE) and Administrative Law Judge (ALJ) as needed, ensuring exhibits include claim records, authorizations, research summary, evidence of coverage, timelines, and documentation are complete, accurate, and well‐organized. Provides clear, comprehensive explanations of denial decisions, benefit coverage, and case handling.
• Investigate and analyze member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history to validate accuracy, ensure proper configuration and adjudication, and confirm case completeness and compliance with all regulatory, contractual, and organizational requirements.
• Apply critical thinking to determine root cause, validate findings, and recommend appropriate resolutions or corrective actions, while drafting clear, accurate written determinations and correspondence within required turnaround times to ensure messaging is professional and customer‑friendly.
• Prepare comprehensive appeal files to be presented to Leadership Appeals Workgroup and for submission to independent external reviewers (IRE), ensuring files include all relevant documentation, claim charts, medical records, Evidence of Coverage, and other Plan documents.
• Search and review all phone calls (listening to each to determine how the call was handled) related to the case and summarize findings.
• Consult with Legal, Compliance and Regulatory Affairs when escalated cases require regulatory review or litigation; may testify on behalf of the organization.
• Validate medical claims by cross rencing the member’s Evidence of Coverage (EOC) or State Medicaid contract with benefit configuration/coding to confirm services are correctly covered and adjudicated.
• Perform detailed root cause analysis to identify trends, errors, and systemic issues contributing to escalated complaints, then recommend corrective actions and process improvements to prevent future appeals and reduce administrative exceptions.
• Coordinate with all involved business areas to gather facts and ensure a full understanding of the applicable benefit contract.
• Authorize administrative exceptions,…