Policy 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. About the Role Responsible for reviewing medical policies, preparing cases for clinical review, and tracking additional information requests for end to end resolution of clinical claims and service request/correspondence inquiries. What You'll Do Responsibilities: 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 the appropriate claim processing or clinical review process decisions. Coordinate the 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