Appeals Resolution Analyst II – RN

Job not on LinkedIn

🕒 August 19

🦌 Connecticut, New Jersey, +2 more states – Remote

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

💵 $79.1k - $105.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

👻 Ghost score 16%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• 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

🎯 Requirements

• 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

🏖️ Benefits

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