Appeals Resolution Analyst II – RN

Job not on LinkedIn

🔥 1 minute ago

🦌 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 20%

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 inpatient level of 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 records for Medical Director review as appropriate. • Investigate and resolve complicated appeals, coordinating with the legal department as necessary, including appeals concerning pre-existing conditions. • Investigate and resolve high-priority cases involving DOBI and Executive inquiries. • Prepare and present appeals to the Appeals Committee, coordinating with independent URO. • Present the appeals process to internal customers and assist Delegate and Vendor Oversight with vendor 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 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 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 as 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. • 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 apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making. • Requires the ability to utilize a personal computer and applicable software. • Strong negotiation skills with demonstrated sales ability to convert prospect to client, in addition to 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 and ability to manage multiple priorities, deliver timely and accurate work products with a customer service focus, and respond with urgency. • Ability to work in a production-focused environment. • Proven ability to exercise sound judgment and strong problem-solving skills. • Proven ability to ask probing questions and obtain thorough and relevant information. • Client service focus with effective ability to empathize. • Employees 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