Medical Policy Specialist I

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

This position is responsible for research and development of Plan medical policy in conjunction with medical director and/or manager. This includes coordination of policy implementation and dissemination of Medical Policy updates across the enterprise. In addition, this position must review annual code changes and determine the impact on medical policies. This position will also serve as a Subject Matter Expert on medical policy to the enterprise.

What You'll Do

• Review and analyze various sources of clinical and health related technology to keep abreast of new medical technology requiring development of Plan policy.

• Actively participates in Medical Policy Committees and related functions.

• Advises the implementation of Medical Policy in cooperation with the Medical Policy Integration team.

• Maintain Medical Policy resource data supportive of Plan policy.

• Review and update annually all existing Horizon medical policies.

• Review issues identified through retrospective utilization review and coordinate activity with Utilization Review/Medical Policy to effectively resolve.

• Assists as needed in the review and analysis of various sources of clinical and health related technology to inform the development of Plan policy. Assists as needed in the research and development of Plan medical policy in conjunction with the medical director and/or manager.

• Demonstrates knowledge and understanding of the laws regulations and policies that pertain to the organization unit's business and conforms to these laws, regulations and policies in carrying out the accountabilities of the job.

• Participates in special projects as directed by management to improve unit functioning and assist in meeting Plan goals.

What You Bring

Education/Experience:

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Requires minimum three (3) years clinical nursing/physician experience.

• Requires minimum three (3) years medical claims processing experience.

Additional licensing, certifications, registrations:

• Requires a Registered Nurse (RN) license or foreign trained physician.

Knowledge:

• Requires in depth knowledge of anatomy and physiology.

• Requires knowledge of health care delivery systems.

• Requires in depth knowledge of CPT, ICD-9/10, and HCPC coding structure.

• Requires working knowledge of medical policy processing and files.

Skills and Abilities:

• Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

• Must have demonstrated ability to deliver highly technical information to less technical individuals.

• Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.

• Must have proven time management skills.

• Proven ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. Demonstrated ability to work in a production focused environment.

• Proven ability to exercise sound judgment and strong problem solving skills.

• Proven ability to ask probing questions and obtain thorough and relevant information.

• Must be client service focused with effective ability to empathize.

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint), Lotus Notes and Outlook; should be knowledgeable in the use of intranet and internet applications.

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth.  We believe that when our people thrive, our communities do too.  If you are passionate about making an impact, we’d love to hear from you!

Salary Range:

$87,300 - $119,070

​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:

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