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More Than 100 Years of Earning Trust
Appeals Analyst II – RN
Location
New Jersey
Posted
7 days ago
Salary
$79.1K - $105.9K / year
Seniority
Senior
Job Description
Appeals Analyst II – RN
NJM Insurance Group
• Handle all Utilization Management medical appeal cases • Ensure timeliness guidelines are met and appeals handled in compliance with regulatory requirements • Provide mentoring and clinical liaison support to appeals staff • Assess patient's clinical need against established guidelines • Evaluate the necessity, appropriateness and efficiency of medical services • Perform review of medical records • Investigate and resolve complicated appeals • Prepare and present appeals to Appeals Committee • Document accurately and comprehensively • Interact and communicate with facilities, physicians and members/families • Evaluate care by problem solving and analyzing variances • Facilitate the external review process with the IURO and IRO • Provide 24/7 on call appeal support as scheduled
Job Requirements
- 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
- Requires working knowledge of principles of utilization management
- Requires knowledge of health care contracts and benefit eligibility requirements
- Requires knowledge of hospital structures and payment systems
- Requires excellent oral and written communication skills
- Requires the ability to work in a high volume environment with moderate supervision
- Requires the ability to utilize a personal computer and applicable software
- Strong negotiation skills
- Must have effective verbal and written communication skills
- Demonstrated ability to deliver highly technical information to less technical individuals
- Must demonstrate professional and ethical business practices
- Proven time management skills are necessary
- Must demonstrate the ability to manage multiple priorities
Benefits
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
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