Claims Negotiation Analyst (Out of Network Mandates)

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.

Education/Experience What You Bring

• 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 pro…