OON Mandate Arbitration Analyst

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

What You'll Do

Job Responsibilities:

• Prepare factual investigation files and research summary including root cause summary analysis as outlined on Litigation Document, Subpoena Request, Administrative Law Case Request, Commission Appeals/2nd Level Administrative appeals and NSA files (and/or other outside agency research request).
• Analysis of data including but not limited to claim charts, medical authorizations, call records, provider requests, appeals, complaints, correspondence and other documents related to the requested case.
• Summarize a justification for the legal, Exec/Reg, or other department regarding Horizon's claim handling, including but not limited to member benefits, contracts, payment methodology, mandate policies and procedures.
• Provide reports as needed for the case. May include requests for informatics reports.
• Search and review all phone calls (listening to each to determine how the call was handled) related to the case and summarize findings.
• Request and provide copies of relevant documents, including but not limited to: Summary Plan Documents and Contracts, NSA negotiation and/or arbitration documents.
• Review contracts for appropriate application of benefits/mandates.
• Assess cause of complaint/appeal/legal case and determines the root cause of errors. Shares root cause with the appropriate Service Teams for re-education.
• Recommends actions to the legal department on LDR cases based on case file review, i.e., overturn a denial due to an authorization that was on file, or claim payment that was not made correctly.
• Other duties as assigned or needed by the Legal Department, by the Commission, Department of Banking and Insurance and/or another agency.
• Attendance at Deposition Hearings, Administrative Law Hearings, Commission Meetings and other outside Committee meetings requiring subject matter expertise by the preparer of the files.
  

What You Bring

Education/Experience:

• High School Diploma/GED required
• Requires seven years of business experience which must include 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
• In lieu of seven years of experience, Bachelor's and 4+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries is acceptable.
• Healthcare industry experience required.
• Experience in complex claims processing necessary.
• Prior OON Mandate, Complaint/appeals handling experience preferred.
• Ability to navigate various claims and service operations systems to obtain the necessary case information.

Knowledge:

• Knowledge of OON State and Federal Mandates required
• Knowledge of HBCBSNJ complaints and appeals process preferred
• Knowledge of insurance claim and membership systems required
• Knowledge of medical terminology, COB, Medicare procedures required
• Knowledge of NCompass and Nasco required
• Knowledge of Claims Policy guidelines required
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products, (Word, Excel, PowerPoint and Outlook).

Skills and Abilities:

• Requires the ability to understand and use language correctly
• Requires the ability to read, understand and interpret written materials.
• Requires the ability to analyze information and to understand and apply rules and procedures
• Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder
• Must be able to detail member/provider-specific issues through the development of individual correspondence for each case explaining all issues in a comprehensive, understandable fashion
• Excellent interpersonal skills (i.e. active listening)
• Strong research, investigative, analytical and problem solving skills
• Requires the ability to handle confidential, proprietary, and privileged information with total discretion.
• Ability to multitask
• Time management skills

Travel:

• Some travel may be required.

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:

​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

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.