Appeals Resolution Analyst II-RN

IntelliResume; New Jersey; On-site; USD 79,000 - 106,000; Full time

Benefits offered by this job

Comprehensive health benefits

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a skilled RN to manage utilization appeals and ensure regulatory compliance in a healthcare management setting. The role focuses on evaluating medical necessity, reviewing records, and coordinating with the Appeals Committee and legal team as needed.

Candidates should have an RN license and 2 years of clinical experience, plus 3 years in healthcare delivery.

Qualifications

• RN license required.
• 2 years clinical experience.
• 3 years experience in health care delivery system/industry.

Responsibilities

• Assess patient clinical needs against guidelines and standards.
• Evaluate necessity and appropriateness of medical services.
• Review medical records and prepare for Medical Director review.
• Investigate and resolve complex appeals with legal coordination.
• Handle appeals concerning pre-existing conditions.
• Investigate and resolve high priority cases involving DOBI and Executive inquiries.
• Prepare and present appeals to Appeals Committee.
• Present the appeals process to internal customers.
• Plan resource allocation for quality patient care.
• Document according to standards and policies.

Education

High School Diploma/GED

Bachelor degree in health care management or relevant experience

Job description

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.

Highlights

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

What You'll Do

• 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.

Requirements

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

Benefits

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

About Horizon Blue Cross Blue Shield NJ

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.