Appeals Analyst II – RN

NJM Insurance Group

Appeals Analyst II responsible for managing Utilization Management medical appeal cases. Ensuring compliance with regulatory requirements and providing support to appeals staff and patients.

Posted 7/14/2026full-timeRemote • New Jersey • 🇺🇸 United StatesMid-LevelSenior💰 $79,100 - $105,945 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management, including handling medical appeals, assessing clinical needs, and ensuring compliance with regulatory requirements. Possesses strong communication and negotiation skills to effectively interact with healthcare professionals and manage multiple priorities.

Highest-signal resume keywords

Utilization ManagementRegistered Nurse LicenseClinical ExperienceHealth Care Delivery SystemNegotiation Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record ReviewClinical AssessmentAppeals PreparationRegulatory ComplianceProblem SolvingDocumentationExternal Review FacilitationHealth Care Contracts KnowledgeBenefit Eligibility RequirementsHospital Structures Knowledge

Soft Skills

Excellent Communication SkillsTime ManagementAbility to Manage Multiple PrioritiesProfessional and Ethical PracticesMentoring

Tools & Technologies

Personal ComputerApplicable Software

Certifications & Qualifications

High School Diploma/GEDBachelor Degree in Health Care Management (Preferred)

Industry Keywords

Utilization Management PrinciplesHealth Care IndustryMedical AppealsClinical Liaison SupportOn Call Appeal Support

About the role

Key responsibilities & impact

Handle all Utilization Management medical appeal cases
Ensure timeliness guidelines are met and appeals handled in compliance with regulatory requirements
Provide mentoring and clinical liaison support to appeals staff
Assess patient's clinical need against established guidelines
Evaluate the necessity, appropriateness and efficiency of medical services
Perform review of medical records
Investigate and resolve complicated appeals
Prepare and present appeals to Appeals Committee
Document accurately and comprehensively
Interact and communicate with facilities, physicians and members/families
Evaluate care by problem solving and analyzing variances
Facilitate the external review process with the IURO and IRO
Provide 24/7 on call appeal support as scheduled

Requirements

What you’ll need

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 have effective verbal and written communication skills
Demonstrated ability to deliver highly technical information to less technical individuals
Must demonstrate professional and ethical business practices
Proven time management skills are necessary
Must demonstrate the ability to manage multiple priorities

Benefits

Comp & perks

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