RN Appeals & Utilization Analyst II: Impactful Healthcare

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

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.