Key Client Support Specialist

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

• Review claims in NASCO (claims processing application) to confirm audit savings. In addition, identify and analyze claims which have been resubmitted by the provider so that savings can be adjusted.

• Review claims which have been reversed or overturned and update/adjust savings.

• Reconcile claims pending vendor recommendation and coordinate with the operations team to process claim based on vendor recommendation.

• Review and update the inpatient provider arrangement file (quarterly) based on details available in the Contract Terms Repository application after review of the latest contracts.

• Analyze data discrepancies noted by internal teams/vendor and coordinate with provider team to ensure corrections are applied to avoid data related errors.

• Manage provider escalations for missed SLAs, review and coordinate with required teams (IT team, vendor or claims team) to resolve the escalation.

• In case of any provider escalation against vendor audit decision - Review audit findings (using DMS) to understand the audit determination and engage Clinical team for detailed clinical review to reverse or uphold the vendor audit determination.

• Analyze claim audit data and identify trends which needs to be worked with clinical (claims/authorization) team for any new process changes that will minimize external audit findings.

• Track and summarize the overall audit savings (Postpay and Prepay) along with claim counts.

• Review audit recommendation applied by the team in Postpay and identify claims pending recovery.

• Coordinate with internal teams to review and understand existing medical, reimbursement policies when new audit concepts/criterias are proposed (by State/vendor) and identify updates to these policies to limit audit findings.

• Provide monthly ITS sample report to State by consolidating CFA reports (in Monarch) and perform data integrity checks on applicable EOBs and EOPs.

• Create annual reports which tracks the overall spend by State on Bluecard claims by Host State, diagnosis code and compare the reports for trends and variances.

• Annual reconciliation of claim paid amount between Horizon and HMS, if the variance is over an acceptable threshold then analyze and rectify the issue so that claim paid amounts are reconciled.

Education/Experience:

• Minimum high school diploma or GED

• Prefers Bachelors degree from an accredited college or university.

• Requires a minimum of 10 years of experience in group health.

• Experience managing in a fast paced, performance driven environment necessary.

Knowledge:

• Must be proficient in the use of personal computers and supporting software in a Windows based environment.

• ClearQuest preferred

• NASCO

• CIRRUS

• Data Management System (DMS) preferred

• SDLC - Waterfall and Agile is a plus

• Knowledge of health insurance plans, health care delivery systems, and claim operations.

• Knowledge and understanding of pricing and underwriting principals.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.