This position is responsible for the research, investigation and follow-up to resolution of member and/or provider complaints for Horizon NJ Health and ensures timeliness guidelines and accuracy standards are met.
Researches, investigates and coordinates resolution to member and/or provider complaints.
Utilizes IMAC database to extract complaint information and tracking log.
Ensures complaint resolutions meet State timing requirements to ensure compliance.
Gathers data to compile monthly and quarterly statistical reports.
Conducts extensive follow-up with internal areas.
Writes complaint resolution letters to physicians and members.
Reviews the complaint database report weekly and follow-up on outstanding issues.
Completes and/or assist with monthly reporting requirements.
Performs any other duties as assigned by management.
Core Individual Contributor Competencies:
Personal and professional attributes that are critical to successful performance for Individual Contributors:
- Prefers a Bachelor's degree from an accredited college or university.
- Requires 2 years customer service or health care experience.
- Requires knowledge of health care delivery systems.
- Requires knowledge of PC's and related software.
- Prefers knowledge of State and Federal regulations
Skills and Abilities:
- Requires strong verbal and written communications skills
- Requires strong analytical and logical thinking.
- Requires use of good grammar, diction and articulation.
- Requires good computer skills.
- Requires conflict resolution skills.
- Requires customer focus with excellent listening skills.
- Requires focus on quality.
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.