Appeals Analyst II – RN

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🔥 10 minutes ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $79.1k - $105.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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NJM Insurance Group

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1913

Insurance

NJM Insurance Group is a well-established insurance provider offering a range of personal and commercial insurance products. Their services include auto, homeowners, renters, condo, commercial auto, and business insurance, with a focus on exceptional customer satisfaction and claims experience. NJM is recognized for its outstanding auto claims experience by J. D. Power and is committed to serving customers in states like Connecticut, Maryland, New Jersey, Ohio, and Pennsylvania. The company prides itself on being straightforward and customer-focused, without jingles or mascots, offering trusted insurance solutions and multiple discount opportunities for various policies.

📋 Description

• Handle all Utilization Management medical appeal cases • Ensure timeliness guidelines are met and appeals handled in compliance with regulatory requirements • Provide mentoring and clinical liaison support to appeals staff • Assess patient's clinical need against established guidelines • Evaluate the necessity, appropriateness and efficiency of medical services • Perform review of medical records • Investigate and resolve complicated appeals • Prepare and present appeals to Appeals Committee • Document accurately and comprehensively • Interact and communicate with facilities, physicians and members/families • Evaluate care by problem solving and analyzing variances • Facilitate the external review process with the IURO and IRO • Provide 24/7 on call appeal support as scheduled

🎯 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 • Requires working knowledge of principles of utilization management • Requires knowledge of health care contracts and benefit eligibility requirements • Requires knowledge of hospital structures and payment systems • Requires excellent oral and written communication skills • Requires the ability to work in a high volume environment with moderate supervision • Requires the ability to utilize a personal computer and applicable software • Strong negotiation skills • Must have effective verbal and written communication skills • Demonstrated ability to deliver highly technical information to less technical individuals • Must demonstrate professional and ethical business practices • Proven time management skills are necessary • Must demonstrate the ability to manage multiple priorities

🏖️ Benefits

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