<p><b><a href="https://himalayas.app/companies/horizon-blue-cross-blue-shield-of-new-jersey">Horizon Blue Cross Blue Shield of New Jersey</a></b> empowers our members to achieve their best health. For over <b>90 years</b>, 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 <b>3.5 million</b> 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. </p><h3>About the Role</h3>This 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.<h3>What You'll Do</h3><ul> <li><p>Performs reviews of post service medical necessity and appealed claims for compliance with appropriate medical policy, plan benefit and correct/appropriate provide coding.</p></li> <li><p>Prepares cases for Medical Director and or outside consultant review and response where appropriate.</p></li> <li><p>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.</p></li> <li><p>Communicates identified opportunities for development of or revisions to Horizon Medical Policies based on case review outcomes.</p></li> <li><p>Manages assigned inventory, documenting production and following assignments through completion.</p></li> <li><p>Stays abreast of mandates, policy and workflow changes impacting review process and outcomes.</p></li> <li><p>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 job</p></li> </ul><h3>What You Bring</h3><h3>Education/Experience<b>:</b> </h3><ul> <li><h3><b>High School Diploma/GED required</b></h3></li> <li><p><b>Requires a minimum of 3 years’ clinical nursing experience</b></p></li> </ul><h3> <b>Skills and Abilities</b><b>:</b> </h3><ul> <li><p><b>Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.</b></p></li> <li><p><b>Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.</b></p></li> <li><p><b>Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities or tasks, deliver timely and ac