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, including conducting investigations, preparing comprehensive appeal files, and validating medical claims against policies and regulations. Proficient in effective communication, problem-solving, and analytical skills to enhance member experience and drive quality improvement.

Highest-signal resume keywords

Claims ProcessingMedical TerminologyHealth Insurance KnowledgeMicrosoft Office SuiteCustomer Service Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims Policy GuidelinesQuantitative ReasoningRoot Cause AnalysisBenefit ConfigurationCoding ValidationAdministrative Law HearingsDocumentation ManagementComplex Claims ProcessingEvidence of CoverageTelephone Customer Service

Soft Skills

Effective CommunicationActive ListeningProblem-SolvingTime ManagementInterpersonal Skills

Industry Keywords

Medicare RegulationsMedicaid GuidelinesGrievances and AppealsInsurance Claim SystemsBenefit Contracts

About the role

Key responsibilities & impact

Manage end-to-end complaint and appeal cases
Conduct investigations by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history
Prepare comprehensive appeal files with claim records, authorizations, research summaries, Evidence of Coverage, medical records, timelines, exhibits, and other Plan documents
Present cases to the Leadership Appeals Workgroup
Coordinate submissions to independent external reviewers and Administrative Law Judges as needed
Draft clear written determinations and customer-friendly correspondence within required turnaround times
Search, listen to, and summarize all phone calls related to cases
Consult with Legal, Compliance, and Regulatory Affairs on escalated cases
Testify on behalf of the organization and attend Administrative Law hearings as needed
Validate medical claims against Evidence of Coverage or State Medicaid contracts, benefit configuration, and coding
Perform root cause analysis to identify trends, errors, and systemic issues
Recommend corrective actions and process improvements
Coordinate with business areas to gather facts and understand benefit contracts
Authorize administrative exceptions, including higher-threshold claim adjustments
Maintain detailed tracking and documentation
Analyze trends to drive quality improvement and enhance member experience
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 accurate calculations
Ability to read and interpret complex written materials
Sound judgment in analytical or mathematical methods
Ability to analyze information and apply rules, policies, and procedures
Professional business correspondence skills
Ability to communicate technical details accessibly and prepare case-specific correspondence
Strong interpersonal skills, including active listening
Research, analytical, and problem-solving skills
Ability to manage multiple priorities
De-escalation techniques for difficult or irate callers
Effective time-management skills
Employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware
The Employer may require an applicant to pass test(s) to determine minimum qualifications

Benefits

Comp & perks

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