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

Job Summary:

This office based position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members and Member Service Coordinators.

Responsibilities:

• Performs review of managed long term support and services requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physician/member
• Handles initial screening for pre-certification requests from physicians/members via incoming calls or correspondence based on scripts and workflows, and under the oversight of clinical staff.
• Prepare, document and route cases in appropriate system for clinical review.
• Initiates call backs and correspondence to members and providers to coordinate and clarify managed long term support and services
• Upon completion of inquiries initiate call back or correspondence to Physicians/Members to coordinate/clarify case completion.
• Reviewing professional medical/claim policy related issues or claims in pending status.
• MCC can generate an authorization for services based upon clinical staff review. *Non Clinical staff members are not responsible for conducting any UM review activities.*
• Member mailings
• Perform other relevant tasks as assigned by Management.

Education:

• High School Diploma required. Some College preferred.

Work experience:

• Prefer 1-2 years customer service or medical support related position.

Specialized knowledge/skills:

• Requires knowledge of medical terminology
• Requires Good Oral and Written Communication skills
• Requires ability to make sound decisions under the direction of Supervisor
• Prefer knowledge of contracts, enrollment, billing & claims coding/processing
• Prefer knowledge Managed Care principles
• Prefer experience with the elderly frail or Managed Medicaid population
• Prefer the ability to analyze and resolve problems with minimal supervision
• Prefer the ability to use a personal computer and applicable software
• Team Player, Strong Analytical, Interpersonal Skills
• Bilingual language skills preferred.

Salary Range:

$43,300 - $57,960

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

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.

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.