Remote Appeals Resolution Analyst II (RN)

Horizon Blue Cross Blue Shield; Northern (KY); Hybrid; 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 an Appeals Resolution Analyst II‑RN to handle medical appeal cases in a remote role based out of Hopewell, NJ.

Responsibilities include assessing clinical need against guidelines, coordinating with legal and external reviews, mentoring staff, and presenting appeals to committees while ensuring regulatory compliance and efficient, patient-focused care.

Qualifications

• High School Diploma/GED required.
• Bachelor degree in health care management preferred or relevant experience.
• Requires 2 years clinical experience and 3 years in the health care delivery system.
• Requires a Registered Nurse License.

Responsibilities

• Assess patient\'s clinical need against guidelines to ensure medically appropriate inpatient care.
• Evaluate necessity, appropriateness and efficiency of medical services and procedures.
• Review medical records and prepare for Medical Director review as appropriate.
• Investigate and resolve complex appeals, coordinating with legal as needed.
• Handle high priority cases involving DOBI and executive inquiries.
• Prepare and present appeals to Appeals Committee with coordination with independent URO.
• Document accurately per standards and communicate with facilities, physicians, and members.

Skills

Negotiation

Communication

Time management

Multitasking

Client service

Education

Bachelor's degree in health care management

Registered Nurse License

High School Diploma/GED

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking an Appeals Resolution Analyst II‑RN to handle medical appeal cases in a remote role based out of Hopewell, NJ.

Responsibilities include assessing clinical need against guidelines, coordinating with legal and external reviews, mentoring staff, and presenting appeals to committees while ensuring regulatory compliance and efficient, patient-focused care.