Mid Level Contract Compliance Specialist Jobs

INTRODUCTION

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 the accurate and timely configuration and maintenance of provider reimbursement arrangements for healthcare professionals, institutions and ancillaries.

Candidate MUST have: Strong analytical skills dealing with hospitals, ancillary and provider contracts.

Responsibilities:

• Interpret company reimbursement arrangements for healthcare professionals, Institutions and ancillaries.
• Consults with relevant contract manager or reimbursement lead to determine appropriate interpretation and configuration of contract terms.
• Unit test simple configuration changes to ensure accuracy of rate load.
• Respond to internal and external provider fee requests.
• Performs problem resolution of configuration issues identified by the Service division or Provider Relations area.
• Monitors and tests the accuracy of price rules, fee schedules, contract loads as assigned.
• Assists with audit function to support both internal and external audits required by the company (SOX, SSAE16).
• Assist the Leads in the implementation of enterprise initiatives impacting pricing.
• Understanding of medical terminology, medical coding (CPT4, ICD9/ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

EDUCATION/EXPERIENCE:

• High School Diploma/GED required.
• Requires 3-5 years of Health Care experience specifically in provider contract and pricing configuration.
• In lieu of degree, requires 5 years of Health Care experience, specifically in provider contract and pricing configuration.
• Requires prior experience in one or more claim systems.
• Requires experience with pricing and/or provider contract arrangements.
• Prefers experience with NetworX Pricer and NetworX PBA.
• Prefers knowledge of one or more claim system with preference in claims processing, pricing and contract set up.

KNOWLEDGE:

• Prefers knowledge of business and technical requirements.
• Prefer Claims processing systems knowledge.
• Prefer knowledge of testing life cycle.
• Working knowledge of MS tools, including MS Office products, MS Access, SQL Server.

SKILLS AND ABILITIES:

• Excellent Communication and presentation skills (Verbal and written) since this is a direct business facing role.
• Must be client service focused with effective ability to empathize.
• Needs to demonstrate willingness to cross-train, and be cross-trained, in other roles/duties.
• Must be detail oriented with strong organizational and data processing skills.
• Proven ability to follow detailed instructions is essential, along with proven problem solving skills.
• Proven analytical, research and problem solving skills a must.
• Must demonstrate the ability to learn quickly and apply learning to new situations. Must exhibit flexibility to change as appropriate.
• Exhibits an energetic, inquisitive, positive approach to problem solving.
• Ability to maintain attendance to support required quality and quantity of work.
• Multi-tasking skills and planning for prioritizing workload.

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:

$70,500 - $94,395

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

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.