UM Appeals Analyst – MAC

NJM Insurance Group

UM Appeals Analyst supporting healthcare operations and member appeals process in New Jersey. Mentoring junior staff and collaborating with medical directors for effective appeals handling.

Posted 4/22/2026full-timeRemote • New Jersey • 🇺🇸 United StatesMid-LevelSenior💰 $63,000 - $84,420 per yearWebsite

About the role

Key responsibilities & impact

This position supports the Health Services and Utilization Management functions and acts as a liaison between Members, Physicians, Delegates, Operational Business members, and Member Service Coordinators.
The incumbent prepares/presents appeals cases and participates in the Horizon Member Appeals Committee (MAC) & Expedited Subcommittee hearings.
Incumbent will mentor more junior staff by responding to questions and sharing expertise.
Performs review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data from physicians/patients.
Handles initial screening for UM Appeals requests from physicians/members/facilities/authorized representatives via incoming calls or correspondence based on workflows.
Interacts with and supports Medical Directors.
Schedule and arrange peer to peer discussions with physicians and our Horizon Medical Directors.
Prepare, document and route cases in appropriate system for clinical review.
Responsible for the comprehensive explanation of previous denials, the scope of coverage, applied criteria, and how the case was handled.
Responsible for addressing questions posed by the appellant or committee and administrative support of completing the appeals process.
Conducts and provides root cause analysis to avoid future appeal occurrences.
Works with supervisor to develop and deliver refresher training to business teams on proper appeal referral, handling, and MAC case preparation.
Assists in the development of junior staff through mentoring, coaching and assisting them in the proper handling of appeal cases.
Assist with running and validating reports for the team.
Perform other relevant tasks as assigned by Management.

Requirements

What you’ll need

High School Diploma/GED required.
Requires minimum of 5 years healthcare industry or operations experience.
Requires minimum 3 years direct customer service experience, preferably in a medical support related position.
Prefer experience with prior appeals handling and correspondence.
Requires knowledge of medical terminology.
Prefer knowledge of UCSW, Medical Policy guidelines, and Care Radius.
Prefer knowledge of contracts, enrollment, billing, & claims coding/processing.
Prefer knowledge of Managed Care principles.
Requires strong oral and written communication skills.
Requires ability to make sound decisions under the direction of the supervisor.
Prefer the ability to analyze and resolve problems with minimal supervision.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Microsoft Outlook).

Benefits

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical terminologyappeals handlingcustomer serviceroot cause analysisclaims codingbillingenrollmentManaged Care principlesUCSWCare Radius

Soft Skills

oral communicationwritten communicationdecision makingproblem analysismentoringcoachingtraining deliveryinterpersonal skillsorganizational skillscollaboration

Certifications

High School DiplomaGED