Appeals Resolution Analyst II – RN
NJM Insurance Group
full-time
Posted on:
Location Type: Remote
Location: New Jersey • United States
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Salary
💰 $79,100 - $105,945 per year
About the role
- Handling all Utilization Management medical appeal cases
- Ensuring that timeliness guidelines are met and appeal handled in compliance with regulatory requirements
- Providing mentoring and clinical liaison support to appeals staff
- Assessing patient's clinical need against established guidelines and standards
- Evaluating the necessity, appropriateness and efficiency of medical services and procedures
- Performing review of medical records and preparing for review by Medical Director
- Investigating and resolving complicated appeals
- Coordinating with legal department as necessary
- Preparing and presenting appeals to Appeals Committee
- Conducting presentations of appeals process to internal customers
- Plans appropriate allocation of resources to provide quality patient care
- Documenting accurately and comprehensively
- Interacting and communicating with facilities, physicians and members/families
- Evaluating care by problem solving and analyzing variances
- Facilitating the external review process with the IURO and IRO
- Providing 24/7 on call appeal support as scheduled
- Actively participating in enterprise meetings as management's proxy
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 demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
utilization managementclinical experiencemedical record reviewappeals processproblem solvingnegotiation skillshealth care contractsbenefit eligibilityhospital structurespayment systems
Soft Skills
mentoringcommunication skillsresource allocationpresentation skillsinterpersonal skillsanalytical skillsprofessional ethicscommitment to developmentteam participationhigh volume environment adaptability
Certifications
Registered Nurse License