Appeals Resolution Analyst II – RN

Job not on LinkedIn

🔥 0 minutes 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

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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 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.

🎯 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 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.

🏖️ Benefits

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