Appeals Resolution Analyst

Horizon Connect @ Wall BCBSNJ

. Manage the end-to-end appeals process, including receiving appeals, entering data into the medical management system, facilitating external vendor review, and completing cases timely.

Posted 9/18/2026full-timeRemote • Connecticut • United StatesJunior💰 $44,600 - $59,745 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing the appeals process within healthcare, including knowledge of CPT-4 and ICD-9 coding, medical terminology, and healthcare delivery systems. Strong communication and analytical skills are essential for effective collaboration with providers, members, and vendors.

Highest-signal resume keywords

Appeals Process ManagementUtilization Management ExperienceKnowledge of CPT-4 and ICD-9 CodingStrong Oral and Written Communication SkillsHealthcare Delivery Systems Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

CPT-4 CodingICD-9 CodingMedical TerminologyData EntryAnalytical ThinkingAppeals Case ResolutionUtilization ManagementAcute Care ExperienceRehabilitation ExperienceTyping 25 WPM

Soft Skills

Strong Communication SkillsLogical ThinkingGood GrammarDictionArticulation

Tools & Technologies

Medical Management Systems

Industry Keywords

Healthcare InsuranceNCQA StandardsDOBI StandardsRegulatory StandardsGovernment Programs

About the role

Key responsibilities & impact

Manage the end-to-end appeals process, including receiving appeals, entering data into the medical management system, facilitating external vendor review, and completing cases timely.
Speak with providers and members about the appeal process and appeal status.
Answer and triage the appeal Hotline phone queue.
Collaborate with internal and external vendors to process appeals according to NCQA, DOBI, State, and other regulatory standards.
Update authorizations based on appeal outcomes and ensure claims are effectuated timely.
Collaborate with internal customers to ensure notification of appeal outcomes.
Perform testing and projects to meet departmental goals.
Resolve basic clinical appeals for Government Programs under supervision while meeting timeliness and accuracy standards.

Requirements

What you’ll need

Requires a High School diploma or GED.
Bachelor's degree from an accredited college or university preferred.
Prefer a minimum of one (1) year recent acute care medical-surgical or rehabilitation experience.
Prefer one (1) year utilization management experience.
Requires knowledge of health care delivery systems.
Requires knowledge of CPT-4 and ICD-9 coding.
Requires knowledge of medical terminology.
Healthcare insurance experience preferred.
Requires strong oral and written communication skills.
Requires strong analytical and logical thinking.
Requires use of good grammar, diction and articulation.
Prefer ability to type 25 wpm.
Experience with Current Medical Management Systems preferred.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement