Appeals Resolution Analyst II – RN

Vaga não está no LinkedIn

🕒 Agosto 19

🦌 Connecticut, New Jersey, +2 estados a mais – Remoto

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $79.100 - $105.945 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

🧐 Analista

👻 Score fantasma 16%

O que significa: quão provável esta vaga está aberta sem contratação ativa.Como ler: 60% ou mais significa que achamos que é uma vaga fantasma. Pontuações mais baixas preocupam menos.Como pontuamos: tempo em aberto, republicações, vagas abertas vs tamanho do time, rapidez para fechar vagas, e se o salário está divulgado.Observação: é uma estimativa de dados públicos, não um julgamento da empresa. Vagas reais podem ter pontuação alta, então use como uma dica, não como um fato.

Candidatar-se

Encontrar Vagas Remotas Similares

Configurar Alerta de Email para Novas Vagas

📊 Verifique sua pontuação de currículo para esta vaga

Melhore suas chances de conseguir uma entrevista verificando sua pontuação de currículo antes de se candidatar.

Enviar Currículo

Horizon Connect @ Wall BCBSNJ

SiteLinkedInTodas as Vagas

2 - 10 funcionários

⚕️ Seguro de Saúde

🏥 Saúde

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ é uma presença no LinkedIn ou programa/escritório local associado ao Horizon Blue Cross Blue Shield de New Jersey (BCBSNJ). Com base no nome e no contexto, parece estar conectado às operações de seguro de saúde do Horizon BCBSNJ e ao alcance local ou envolvimento de membros/provedores na área de Wall, NJ. As informações disponíveis publicamente são limitadas e consistem principalmente na interface do site do LinkedIn em vez de um perfil da empresa, então essa descrição é conservadora e baseada na afiliação indicada pelo nome.

Descrição

• Handle all Utilization Management medical appeal cases • Ensure timeliness guidelines and regulatory requirements are met, including NCQA, URAC, and NJ/Federal regulations • Provide mentoring and clinical liaison support to appeals staff • Assess patients' clinical needs against established guidelines and standards for medically appropriate inpatient level of care and length of stay • Evaluate the necessity, appropriateness, and efficiency of medical services and procedures by inpatient facilities • Review medical records and prepare records for Medical Director review as appropriate • Investigate and resolve complicated appeals, coordinating with the legal department as necessary • Handle appeals concerning pre-existing conditions • Investigate and resolve high-priority cases involving DOBI and Executive inquiries • Prepare and present appeals to the Appeals Committee, including coordination with an independent URO • Present the appeals process to internal customers • Work with Delegate and Vendor Oversight to help vendors establish compliant appeals procedures • Plan resource allocation to provide quality patient care cost-effectively • Document accurately and comprehensively according to standards of practice and organization policies • Communicate with facilities, physicians, members, and families telephonically and/or onsite • Evaluate care by problem-solving, analyzing variances, and participating in quality improvement programs • Facilitate the external review process with the IURO and IRO • Provide scheduled 24/7 on-call appeal support • Participate in enterprise meetings as management's proxy when necessary • Work specified weekends and holidays as required by regulatory and accrediting standards • Perform special projects assigned by management

🎯 Requisitos

• High School Diploma/GED required • Bachelor degree in health care management preferred or relevant experience in lieu of degree • Requires 2 years clinical experience • Requires 3 years experience in the health care delivery system/industry • Requires a Registered Nurse License • Working knowledge of principles of utilization management • Knowledge of health care contracts and benefit eligibility requirements • Knowledge of hospital structures and payment systems • Excellent oral and written communication skills • Ability to work in a high volume environment with moderate supervision • Ability to apply an understanding of business fundamentals and administrative expense management to day-to-day decision-making • Ability to utilize a personal computer and applicable software • Strong negotiation skills and demonstrated persuasive skills • Effective verbal and written communication skills and ability to work well within a team • Ability to deliver highly technical information to less technical individuals • Professional and ethical business practices and adherence to company standards • Proven time management skills • Ability to manage multiple priorities, deliver timely and accurate work products, respond with a sense of urgency, and maintain a customer service focus • Ability to work in a production-focused environment • Sound judgment and strong problem-solving skills • Ability to ask probing questions and obtain thorough and relevant information • Client-service focus and ability to empathize • Must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware

🏖️ Benefícios

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