Appeals Resolution Analyst II – RN

Vaga não está no LinkedIn

🕒 Agosto 10

🦌 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.

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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 while meeting timeliness guidelines and regulatory requirements. • Assess patients' clinical needs against established guidelines and standards for medically appropriate inpatient care and length of stay. • Evaluate the necessity, appropriateness, and efficiency of medical services and procedures provided by inpatient facilities. • Review medical records and prepare them for Medical Director review as appropriate. • Investigate and resolve complicated appeals, pre-existing-condition appeals, and high-priority DOBI and Executive inquiries. • Prepare and present appeals to the Appeals Committee, coordinating with independent UROs. • Present the appeals process to internal customers and support Delegate and Vendor Oversight with vendor appeals procedures. • Plan resource allocation to provide quality patient care cost-effectively. • Document accurately and comprehensively according to standards of practice and organizational policies. • Communicate with facilities, physicians, members, and families telephonically and/or on site to support continuity and efficiency of care. • Evaluate care by problem-solving, analyzing variances, and participating in quality improvement programs. • Facilitate the external review process with IUROs and IROs. • Provide scheduled 24/7 on-call appeal support. • Participate in enterprise meetings as management's proxy when necessary. • Perform special projects assigned by management. • Work a specified number of weekends and holidays based on regulatory and accrediting-body standards and department business needs.

🎯 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 utilization management principles. • 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 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 sales ability to convert prospects to clients. • Demonstrated persuasive skills with carriers. • 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, adherence to company standards, and commitment to personal and professional development. • Proven time management skills. • Ability to manage multiple priorities or tasks and deliver timely, accurate work products with a customer service focus. • Ability to respond with a sense of urgency as required. • Ability to work in a production-focused environment. • Proven sound judgment and strong problem-solving skills. • Ability to ask probing questions and obtain thorough, relevant information. • Client-service focus and ability to empathize. • Employees 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