United States onlyHorizon 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
This position is responsible for coordinating the implementation of various Association initiatives and projects to support the strategic and operations goals aligned to the IPP Scorecard. The incumbent will work with all levels of management to ensure business objectives are met and processes are implemented.What You'll Do
Provide business requirements, create action plans, and implement new and updated workflows in response to Blue Cross Blue Shield Association audit findings, Association mandates, and enterprise projects.
Consistently monitors various Association policies and procedures to ensure compliance, coordinating training when required.
Resolves common, complex and escalated issues directly impacting provider and member claims by working with other BCBS Health Care Plans, our members or providers.
Identifies operational issues and initiates fixes to eliminate trends of untimely, inaccurate, non-compliant or inconsistent claims adjudication for our participating providers or partner BCBS Health Care Plans involving multiple system and inquiry platforms.
Partners with IT on the implementation of all systemic solutions, performing user acceptance testing where appropriate.
Acts as a liaison between internal divisions and the BCBSA, coordinating National Programs compliance activities aligned to the guidelines of the Association.
Reviews provider files, working directly with IT and other internal partners to correct any issues identified by the BCBSA.
Participates in workgroups hosted by the BCBSA and represents Service Operations on all mandate calls. Ensures that all Blue Card mandates are successfully implemented on time.
BLUE CARD SPECIFIC JOB TASKS
Manages the bulk adjustment process to ensure the identified claims to be adjusted are valid, provides specific bulk adjustment requirements and reviews and approves all mock adjustments.
Responsible for managing error reports coming from the BCBSA, including working with our IT partners to ensure that root causes are identified and remediated and initiating systemic solutions when required.
Manages open inventory with partner plans and internal stakeholders.
Works directly with the IT department, analyzing invalid BlueCard records and submitting work orders to correct the issue.
Develops all reporting requirements for BlueCard inventory.
What You Bring
Education/Experience:
High School Diploma/GED required.
Requires a minimum of 2 years of experience in a relevant field, preferably in operations, and or claims processing environment.
Project management/data analysis experience preferred.
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:
$63,000 - $84,420This 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. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.
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.
