Policy Support Specialist

Horizon Connect @ Wall BCBSNJ

. Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business .

Posted 9/15/2026full-timeRemote • Connecticut • United StatesMid-LevelSenior💰 $52,787 - $70,172 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in health care claims processing, including researching medical records, applying medical terminology, and managing clinical review processes. Proficient in analyzing claims, coordinating benefits, and communicating effectively with members and providers.

Highest-signal resume keywords

Health Care Claims ProcessingMedical TerminologyBilling and CodingCoordination of Benefits (COB)Analytical and Critical Thinking Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Claims ResearchClinical Review ProcessClaim AdjustmentsService Request ManagementPricing Determination

Soft Skills

Organizational SkillsCommunication Skills

Certifications & Qualifications

High School DiplomaGED Equivalent

Industry Keywords

Medical PoliciesHorizon Medical PoliciesLines of BusinessCustomer InquiriesNew JerseyNew YorkPennsylvaniaConnecticutDelaware

About the role

Key responsibilities & impact

Research member medical records to resolve claims or service requests that pend with clinical edits for all lines of business
Review medical policies and determine appropriate claim processing or clinical review process decisions
Coordinate clinical review and appeal processes, including preparing cases for clinical review and requesting additional information from members and providers
Review clinical determinations and initiate appropriate claim adjustments and service request closeout, including drafting manual letters
Review and determine pricing for clinical claims in accordance with negotiated pricing agreements
Review and update Coordination of Benefit (COB) files and submit provider file updates as necessary
Identify technical issues and submit them to the appropriate area for resolution
Handle relevant incoming telephone inquiries as needed
Perform other tasks as assigned by management

Requirements

What you’ll need

Minimum of a High School Diploma or GED equivalent required
Requires three (3) years of health care claims processing experience including researching and investigating customer inquiries
Requires a minimum of two (2) years of experience with medical terminology, billing and coding
Knowledge of COB and Horizon medical policies preferred
Knowledge of all lines of business preferred
Strong analytical and critical thinking skills preferred
Strong organizational and communication skills
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