Senior RN Appeals & Utilization Analyst

Horizon Blue Cross Blue Shield of New Jersey; Hopewell (NJ); On-site; USD 79,000 - 106,000; Full time

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a skilled Utilization Management RN to handle medical appeal cases, ensure timely processing, and maintain regulatory compliance (NCQA, URAC, NJ/Federal). The role includes mentoring staff, coordinating with legal, and supporting 24/7 on-call appeal coverage.

Qualifications include RN license, 2 years clinical experience, and 3 years in healthcare delivery. Bachelor’s in healthcare mgmt preferred or equivalent experience.

Qualifications

• 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.

Responsibilities

• Assess patient’s clinical need against guidelines to ensure appropriate inpatient level of care.
• Evaluate necessity and efficiency of medical services and procedures in inpatient facilities.
• Review medical records and prepare for Medical Director review as appropriate.
• Investigate and resolve complex appeals with coordination with legal when needed.
• Present appeals to Appeals Committee per criteria and coordination with independent URO.
• Plan resource allocation to provide quality patient care cost-effectively.
• Document accurately per standards of practice and policies.
• Interact with facilities, physicians and members/families to ensure continuity of care.

Skills

Utilization management

Communication

Team collaboration

Negotiation

Education

Bachelor degree in health care management

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a skilled Utilization Management RN to handle medical appeal cases, ensure timely processing, and maintain regulatory compliance (NCQA, URAC, NJ/Federal). The role includes mentoring staff, coordinating with legal, and supporting 24/7 on-call appeal coverage.

Qualifications include RN license, 2 years clinical experience, and 3 years in healthcare delivery. Bachelor’s in healthcare mgmt preferred or equivalent experience.