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Policy Support Specialist
Horizon Connect @ Wall BCBSNJCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
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
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 requests 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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ResearchClinical Review ProcessClaim AdjustmentsService RequestsPricing DeterminationMedical Policies ReviewTechnical Issue Identification
Soft Skills
Organizational SkillsCommunication Skills
Certifications & Qualifications
High School DiplomaGED Equivalent
Industry Keywords
Horizon Medical PoliciesLines Of BusinessHealth Care