UM Appeals Analyst – MAC

NJM Insurance Group

Supports healthcare operations as an Appeals Analyst for Horizon Blue Cross Blue Shield. Acts as a liaison and mentors junior staff while managing appeals processes and communications.

Posted 6/3/2026full-timeRemote • New Jersey • 🇺🇸 United StatesMid-LevelSenior💰 $63,000 - $84,420 per yearWebsite

About the role

Key responsibilities & impact

Supports the Health Services and Utilization Management functions
Acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators
Prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings
Mentors more junior staff by responding to questions and sharing expertise
Adheres to all regulated processes and timeframes in accordance with the 1st, 2nd level and Special Process UM Appeal workflows
Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients
Manages correspondence of toll-free UM Appeal hotline and UM Appeal fax server
Interacts with and supports Medical Directors
Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors
Prepares, documents and routes cases in appropriate system for clinical review
Responsible for the comprehensive explanation of previous denials, the scope of coverage, and applied criteria
Conducts and provides root cause analysis to avoid future appeal occurrences.

Requirements

What you’ll need

High School Diploma/GED required
Requires minimum of 5 years healthcare industry or operations experience
Requires minimum 3 years direct customer service experience, preferably in a medical support related position
Prefer experience with prior appeals handling and correspondence
Requires knowledge of medical terminology
Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius
Prefer knowledge of contracts, enrollment, billing, & claims coding/processing
Prefer knowledge of Managed Care principles
Requires strong oral and written communication skills
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Microsoft Outlook)

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical terminologyappeals handlingcustomer serviceclaims codingclaims processingroot cause analysisnon-clinical data collectionstructured clinical data acquisitionManaged Care principlesUCSW

Soft Skills

communication skillsmentoringinterpersonal skillsorganizational skillspresentation skills

Certifications

High School DiplomaGED