GP Appeals Analyst I

Horizon Connect @ Wall BCBSNJ

. Manage end-to-end complaint and appeal cases .

Posted 10/12/2026full-timeRemote • United StatesMid-LevelSenior💰 $63,000 - $84,420 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing complaint and appeal cases within health insurance, utilizing strong analytical and problem-solving skills to investigate and resolve issues. Proficient in drafting professional correspondence and presenting complex information clearly to various stakeholders.

Highest-signal resume keywords

Health Insurance ExperienceClaims Processing KnowledgeMedicare/Medicaid RegulationsAnalytical and Problem-Solving SkillsMicrosoft Office Suite Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Policy Guidelines KnowledgeMedical Terminology KnowledgeQuantitative ReasoningComplex Written Material InterpretationKeyboarding Proficiency

Soft Skills

Effective CommunicationActive ListeningTime-Management SkillsDe-Escalation SkillsInterpersonal Skills

Industry Keywords

Complaint and Appeal ManagementBenefit Coverage AnalysisCustomer Service ExperienceGrievances HandlingCase Tracking and Documentation

About the role

Key responsibilities & impact

Manage end-to-end complaint and appeal cases
Investigate member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history
Prepare comprehensive appeal files for Leadership Appeals Workgroup, independent external reviewers, and Administrative Law Judges
Coordinate submission to independent external reviewers and Administrative Law Judges as needed
Present clear explanations of denial decisions, benefit coverage, and case handling
Apply critical thinking and root-cause analysis to determine findings and recommend resolutions or corrective actions
Draft accurate, professional, customer-friendly written determinations and correspondence within required turnaround times
Search, review, and summarize phone calls related to cases
Consult with Legal, Compliance, and Regulatory Affairs on escalated cases; may testify on behalf of the organization
Validate medical claims against Evidence of Coverage or State Medicaid contracts, benefit configuration, and coding
Identify trends, errors, and systemic issues and recommend process improvements
Coordinate with business areas to gather facts and understand applicable benefit contracts
Authorize administrative exceptions, including higher-threshold claim adjustments
Present cases before the Leadership Appeals Workgroup and attend Administrative Law hearings
Maintain detailed case tracking and documentation
Perform other duties as assigned

Requirements

What you’ll need

High School Diploma/GED required
Bachelor degree preferred or relevant experience in lieu of degree
Four+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries
Experience in health insurance, claim appeals and grievances preferred
Experience in complex claims processing necessary
Prior grievances and appeals handling experience preferred
Knowledge of insurance claim and membership systems required
Knowledge of claim processes, benefits, and claim policy guidelines
Knowledge of medical terminology, COB, Medicare procedures required
Knowledge of Medicare/Medicaid regulations and guidelines
In depth knowledge of Claims Policy guidelines required
Strong knowledge of Microsoft Office Suite required
Keyboarding proficiency
Strong language proficiency and clear, effective communication
Quantitative reasoning and numerical data interpretation
Ability to read and interpret complex written materials
Analytical, mathematical, research, problem-solving, and judgment skills
Ability to produce professional business correspondence conveying complex information clearly
Strong interpersonal skills, including active listening
Ability to manage multiple priorities effectively
De-escalation skills for difficult or irate callers
Effective time-management skills
May be required to pass employment qualification test(s)
Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Remote work arrangement
Some travel may be required