Horizon Blue Cross Blue Shield of New Jersey · 21 hours ago
OON Mandate Negotiation Analyst
Newark, NJ
Full-time
Onsite
Mid, Senior Level
$55K/yr - $73K/yr
5+ years expHorizon Blue Cross Blue Shield of New Jersey is seeking an OON Mandate Negotiation Analyst to manage the resolution of out of network billing disputes. The role involves handling negotiations within regulatory timeframes and maintaining oversight to bring cases to resolution.
Health Care
Responsibilities
Timely and accurate creation and closure of Interactions and Intents and/or open negotiations via the SharePoint site including appropriate coding and updates related to mandate determinations and all applicable attachments for reporting purposes
Completion of eligibility verification upon assignment of new mandated cases including validation services are in scope of the surprise bill mandate, appropriate mandate applies, minimum threshold amount met, non-initiating party met all regulatory timeframes for submission submitting accurate and complete forms
Interacts with relevant parties to facilitate timely and accurate negotiation resolution
Research and review of negotiation attempts including but not limited to pulling of phone calls, authorizations, outreach to providers/billing agencies and attorneys including validation of all information submitted as part of the dispute
Updates to high dollar negotiation files including investigation and research to determine eligibility based upon on the negotiation request document
Prepares written responses including negotiation outcomes by completing a written justification on how Horizon BCBSNJ adjudicated the initial and adjusted claim, but not limited to, benefits, contracts, payment and pricing methodology, proof of plan and providing explanation of benefits within regulated timeframes. Including the handling and response for Escalated complaints from CMS/DOBI/DOL and Legal/Litigation
Accurate and timely adjustments based upon negotiation outcomes within the regulated timeframe including any applicable interest
Conducting any follow up or additional research as deemed appropriate based upon negotiation requests
Conducts detailed root cause analysis, including tracking and trending of errors and omissions that led to escalated complaints and make recommendations to avoid future occurrences
Participate in staff meetings as deemed appropriate
Creation of GSI’s and logging of cases on Blue 2 for ITS Home/Host cases requiring interaction with other Blue’s plans
Perform other duties as required by management
Qualification
Required
High School Diploma/GED required
Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries
Experience in claims processing necessary
Ability to navigate the various claims and service operations systems
Knowledge of Microsoft Office Suite required
Requires the ability to understand and use language correctly, to be determined by the Language skills test
The Employer may require an employee to pass an additional test(s) as a part of determining whether the applicant meets the minimum qualifications for the job
Requires keyboarding proficiency
Requires the ability to perform basic arithmetical calculations
Requires the ability to read, understand and interpret written materials
Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem
Requires the ability to analyze information and to understand and apply rules and procedures
Requires the ability to compose business letters
Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail member-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion
Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers
Excellent interpersonal skills (i.e. active listening)
Strong research, investigative, analytical, decision making and problem solving skills
Ability to perform in high pressure situations
Ability to multitask
Ability to manage and diffuse irate callers
Time management skills
Preferred
Bachelor degree preferred or relevant experience in lieu of degree
Knowledge of HBCBSNJ complaints and appeals process preferred
Knowledge of insurance claim and membership systems preferred
Knowledge of medical terminology, COB, Medicare procedures preferred
Knowledge of UCSW preferred
Knowledge of Claims Policy guidelines preferred
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Company
Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Gary St. Hilaire
President & Chief Executive Officer
Recent News
2026-01-06
2025-12-29
2025-12-25
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