UM Appeals Resolution RN (Analyst II)

Horizon Blue Cross Blue Shield; 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

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking a focused Utilization Management Appeals RN to ensure medical necessity and timely handling of appeal cases. You will mentor staff, coordinate with legal, and review records to support regulatory compliance across NCQA, URAC and NJ/Federal requirements.

Responsibilities include presenting to the Appeals Committee, guiding vendors, and ensuring cost-effective patient care while maintaining high-quality outcomes.

Qualifications

• High School Diploma or 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 inpatient stay is medically appropriate.
• Evaluate necessity and efficiency of medical services by inpatient facilities.
• Review medical records for review by Medical Director as appropriate.
• Investigate and resolve complex appeals, coordinating with legal as necessary.
• Prepare and present appeals to Appeals Committee and coordinate with IURO.
• Provide 24/7 on-call appeal support as scheduled.

Skills

Negotiation

Persuasion

Communication

Teamwork

Education

Bachelor's degree (preferred)

Registered Nurse License

High School Diploma/GED

2 years clinical experience

3 years healthcare delivery experience

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a focused Utilization Management Appeals RN to ensure medical necessity and timely handling of appeal cases. You will mentor staff, coordinate with legal, and review records to support regulatory compliance across NCQA, URAC and NJ/Federal requirements.

Responsibilities include presenting to the Appeals Committee, guiding vendors, and ensuring cost-effective patient care while maintaining high-quality outcomes.