Claims Auditor II

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

Performs audit samples on benefit coding, reimbursement, pricing, PIBA and pharmacy to ensure accurate claim adjudication and reimbursement.

What You'll Do

• Independently review assigned audit samples across PG, LOS, LDLA, and FEP audit programs, including claims, EDI, portal, inquiries, membership, and other operational work types, in accordance with established audit criteria and program-specific guidance.
• Complete assigned audit volumes within established production expectations while maintaining required accuracy, quality, and documentation standards.
• Identify processing errors, variances, or noncompliant outcomes during sample review; cite findings as audit points; and document rationale and supporting evidence clearly, accurately, and independently.
• Manage assigned audit points through follow-up and resolution activities, including communication, validation, documentation updates, and closure within established timeframes.
• Partner with business areas and internal team members to obtain clarification, confirm root cause information, support audit point resolution, and ensure findings are addressed appropriately.
• Use applicable systems and tools to complete audit work and document results, including NASCO, Blue Squared, Local, BlueCard, other supporting operational systems, and the department’s audit tool.
• Maintain complete, accurate, and organized audit documentation to support findings, audit point activity, re-review, reporting, and audit readiness.
• Support consistency across the audit function by participating in calibration activities, sharing knowledge, and assisting with onboarding or guidance for less experienced auditors as appropriate.
• Escalate unclear, conflicting, or complex scenarios to senior auditors or management, as appropriate, while demonstrating sound judgment and increasing independence in audit execution.
• Perform other job-related duties, special assignments, and operational support activities, as assigned by management, to meet departmental, regulatory, and business needs.

What You Bring

• Education/Experience: High School Diploma/GED required.
• 3-5 years of claims processing experience required.
• Knowledge: Systems knowledge (e.g. NASCO).
• 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!

Disclaimer:

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.