Provider Resolution Analyst I

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

Job Summary:

• Completes investigation and root cause analysis of complex claim issues and facilitates their resolution through the proper channels by working with multiple operational areas, analyzing the systems and processes involved in member enrollment, Medicaid State Files, provider information management, benefits configuration and/or claims processing.

• Performs extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers/members and conducting all necessary follow-up with internal departments within regulatory timeframes. Escalates complex issues identified to Provider Resolution Analyst II.

• Performs analysis to assess root cause claim issues or breakdown. Escalate moderately and complex claims issues to Provider Resolution Analyst II. Assist in identifying dependencies that may impact other members, or providers.

• Identify appropriate course of action for resolution and create appropriate issue tracking request for systemic changes by the Configuration Team, Contracting Dept., Pricing Dept., or other internal departments as needed for complete resolution, under the guidance of the PRA II and PRA III

• Acts as a department resource and gives support to Customer Service researching Practice Connect issues for resolution and provider calls for disputes

• Follow up on unresolved issues via outbound calls, emails or faxes.

• Complete the documentation necessary to track provider issues and support overall root cause trending.

Disclaimer:
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.

• High School Diploma/GED required.

• Requires 2+ years claims experience.

• Facets experience preferred, but other claims experience considered

• CPT/HCPC and ICD9 coding, procedures and guidelines

• Prefers knowledge of medical terminology. Strong Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding

• Prefer knowledge of health care industry policies and procedures, knowledge of Medicaid or other Governmental Health Program.

• Prefers knowledge of FACETS or other Medicaid/commercial claims processing platform; knowledge of SharePoint system, Document Management System (DMS).

• Prefersexcellent presentation, oral and written communication skills.

• Requires customer service focus and a problem solving aptitude.

• Requires strong organizational and analytical skills.

• 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; should be knowledgeable in the use of intranet and internet applications.

• Intermediate Ability to work as part of a team.

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

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.