Medicare Auditor 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

Responsible for determining primacy between Medicare and Horizon, identifying overpayments and processing Medicare Demands received from the Medicare Secondary Payer Recovery Contractor or the Department of
U.S. Treasury.

What You'll Do

Responsibilities:

• Review and verify data integrity of Medicare files.

• Determine primacy and coordinate system updates as needed.

• Review End-Stage Renal Disease cases and determine Medicare primacy.

• Review recovery opportunities identified by vendors and determine whether identified recoveries are valid.

• Respond to Medicare-related questions from Account Managers, brokers, groups, members, and other customers.

• Support MSP inventory reporting, MRM hierarchy-error review, and Claimstop/PLOG review

• Using information such as Medicare data, group size, and working status to determine whether Horizon or Medicare is primary

• Process claims to repay Medicare or the Treasury Department following CMS Regulations.

• Update tracking system accordingly.

• Ability to research and apply benefits as needed.

• Ability to read and understand New Membership System (NMS) and Nasco.

• Perform other related tasks as assigned by management.leagues assigned to this job.

What You Bring

Education/Experience:

• High School Diploma/GED required.

• Minimum of 2 years experience in processing and adjusting claims

Knowledge:

• Knowledge of Medicare

• Knowledge of Medicare Secondary Payer regulations

• Knowledge of NMS and Nasco

• Knowledge of Sales internal systems NAEGS and CPL

Skills and Abilities:

• Strong Computer Skills

• Multitasking, strong Interpersonal skills, critical thinking, organizational skills and strong Written and Verbal Skills

• Microsoft Excel

• Microsoft Access

• Microsoft Word

Systems:

• Nasco

• NCompass

• NMS

• FileNet

• Cirrus

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:

$50,100 - $67,095

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:

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.