Utilization & Appeals Nurse Analyst II

100 Horizon Healthcare Services, Inc; Hopewell (NJ); 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 qualified Utilization Management Appeals RN to handle medical appeal cases, ensure timeliness, and maintain regulatory compliance. The role provides mentoring, clinical liaison support, and participates in enterprise meetings while coordinating with the legal team on complex appeals.

Responsibilities include assessing inpatient stay appropriateness, reviewing records for Medical Director, and presenting to the Appeals Committee.

Qualifications

• Requires RN license and clinical experience.
• Bachelor degree preferred or relevant experience in lieu of degree.

Responsibilities

• Assess clinical need against guidelines for inpatient stay.
• Evaluate necessity and efficiency of medical services.
• Review medical records for director review preparation.
• Investigate and resolve complex appeals with legal coordination.
• Present appeals to Appeals Committee and coordinate with IURO/IR0.

Skills

Utilization management

Appeals

Documentation

Communication

Negotiation

Education

Bachelor degree preferred

RN license

Job description

Horizon Blue Cross Blue Shield of New Jersey is seeking a qualified Utilization Management Appeals RN to handle medical appeal cases, ensure timeliness, and maintain regulatory compliance. The role provides mentoring, clinical liaison support, and participates in enterprise meetings while coordinating with the legal team on complex appeals.

Responsibilities include assessing inpatient stay appropriateness, reviewing records for Medical Director, and presenting to the Appeals Committee.