Appeals Resolution Analyst II-RN

About This Role

This position is responsible for handling all Utilization Management medical appeal cases, ensuring compliance with regulatory requirements and providing support to appeals staff. It is ideal for experienced RNs looking to make a significant impact in healthcare management.

• Pay: $79,100 - $105,945/year
• Location: Hopewell, NJ
• Schedule: Full-time

• Assess patient clinical needs against established guidelines and standards.
• Evaluate the necessity and appropriateness of medical services and procedures.
• Perform review of medical records and prepare them for Medical Director review.
• 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.
• Conduct presentations of the appeals process to internal customers.
• Plan appropriate allocation of resources for quality patient care.
• Document accurately based on standards of practice and current organization policies.

Education:

• High School Diploma/GED required
• Bachelor degree in health care management preferred or relevant experience in lieu of degree

Experience:

• 2 years clinical experience required
• 3 years experience in the health care delivery system/industry required

Licenses &

Certifications:

• Current Registered Nurse License required

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

Horizon Blue Cross Blue Shield of New Jersey is a leading health solutions provider committed to delivering exceptional patient care. With over 90 years of experience, they focus on improving healthcare quality, affordability, and member experience for over 3.5 million people.