Appeals Resolution Analyst II-RN

We need to output HTML fragment with sections: About the role, Responsibilities (maybe "What You'll Do"), Requirements (Education/Experience, Additional Licensing, Knowledge, Skills & Abilities), Benefits (Why Horizon? plus compensation and benefits), Pay (Salary Range), maybe Schedule (mention of weekends/holidays). Must not repeat job title. Must not include boilerplate like EEO, disclaimer, etc. Must preserve all substantive info. We need to parse content. First paragraph about Horizon: that's company description, maybe not needed? It's not a section heading; we could include as a

before sections? The instruction: "Output ONLY the HTML fragment — no /, no markdown code fences." It didn't forbid including introductory paragraph. Usually we include the content after the job title. The posting includes a company overview before "About The Role". We could keep that as a

(maybe as an intro). Not a heading. Then we have "About The Role" heading. We'll use

About the Role

then a

with the description: "This position is responsible for handling all Utilization Management medical appeal cases. Ensures that timeliness guidelines are met and appeal handled in compliance with regulatory requirements of various agencies including but not limited to NCQA,URAC and NJ/Federal regulations. Provides mentoring and clinical liaison support to appeals staff. Performs special projects as assigned by management" Next "What You'll Do" is responsibilities. We'll use

Responsibilities

then a

• list each bullet. Need to capture all bullet points. List them: - Assesses patient's clinical need against established guidelines and standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. - Evaluates the necessity, appropriateness and efficiency of medical services and procedures by inpatient facilities. - Performs review of medical records and prepares medical records for review by Medical Director as appropriate. - Investigates and resolves complicated appeals, coordinating with legal department as necessary and handles appeals concerning pre existing conditions. - Investigates and resolves high priority cases involving DOBI and Executive inquiries. - Prepares and presents appeals to Appeals Committee in accordance with criteria including coordination with independent URO. - Conducts presentations of appeals process to internal customers and works with Delegate and Vendor Oversight to assist vendors in establishing procedures to ensure their appeals process complies with requirements. - Plans appropriate allocation of resources to provide quality patient care in the most cost effective manner. - Documents accurately and comprehensively based on the standards of practice and current organization policies. - Interacts and communicates with facilities, physicians and or members/families, either telephonically and or on site striving for continuity and efficiency as the member is managed along the continuum of care. - Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. - Facilitates the external review process with the IURO and IRO. - Provides 24/7 on call appeal support as scheduled. - Actively participates in enterprise meetings as management-s proxy as necessary. - Performs special projects as assigned by management. - Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Note: The last bullet about weekends/holidays could be considered schedule. But we can keep in responsibilities or maybe separate schedule section. Since schedule is mentioned, we could create a Schedule section. However instruction: "Prefer a few substantive sections over many thin ones." Might combine schedule into responsibilities or a separate Schedule section if we have enough content. We have schedule info: "Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs." That's schedule. Could be its own section. We'll decide to put schedule as its own section:

  Schedule

  Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs.

  Now Education/Experience etc. We'll have Requirements section with subpoints? Could break into Education/Experience, Licensing, Knowledge, Skills & Abilities. But we could combine into one Requirements section with lists. We need to preserve all substantive info. Education/Experience: - 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. Additional Licensing, Certifications, Registrations: - Requires a Registered Nurse License. Knowledge: - 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. - Require the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making. Skills & Abilities: - Requires the ability to utilize a personal computer and applicable software. - Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers - Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. - Demonstrated ability to deliver highly technical information to less technical individuals. - Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development. - Proven time management skills are necessary. - Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required. - Demonstrated ability to work in a production focused environment. - Proven ability to exercise sound judgment and strong problem solving skills. - Proven ability to ask probing questions and obtain thorough and relevant information. - Must be client service focused with effective ability to empathize. We could combine Knowledge and Skills & Abilities into one list, but better to separate headings? The instruction: use

  for section headings (e.g. About the role, Responsibilities, Requirements, Qualifications, Skills, Benefits, Pay, Schedule). So we could have separate sections: Requirements (education/experience), Knowledge, Skills, Benefits, Pay, Schedule. But we must avoid thin sections. However each of these have substantive content. We could combine Knowledge and Skills into a single "Requirements" section with subheadings? But we cannot use

  maybe not allowed; only

  for section headings. Could use

  with bold? Not needed. Probably better to have separate sections: Requirements (education/experience + licensing), Knowledge, Skills, Benefits, Pay, Schedule. But we must ensure we don't create sections with filler like "not specified". All have content. Let's outline:

  About the Role

  ...

  Responsibilities

  ...

  Schedule

  ...

  Requirements

  Education/Experience:

  ...

  Licensing:

  ...
  Alternatively we could separate Education/Experience and Licensing as separate sections but that may be thin. We'll combine.

  Knowledge

  ...

  Skills & Abilities

  ...

  Benefits

  Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!

  Horizon also provides a comprehensive compensation and benefits package which includes:

  • Comprehensive health benefits (Medical/Dental/Vision)
  • Retirement Plans
  • Generous PTO
  • Incentive Plans
  • Wellness Programs
  • Paid Volunteer Time Off
  • Tuition Reimbursement

  Pay

  Salary Range $79,100 - $105,945 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

  We should not include the disclaimer about Horizon BCBSNJ employees must live in certain states, nor the job summary disclaimer, nor EEO, etc. Check for any other substantive info: "Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs." Already in Schedule. Now ensure we didn't miss any responsibilities: The list includes "Performs special projects as assigned by management." appears twice (once in About the role and again in responsibilities). We'll keep only one in responsibilities; but we need to preserve all substantive info; duplication is okay but we can deduplicate. The instruction: "Remove duplicated lines". So we should remove duplicate lines. The duplicate "Performs special projects as assigned by management." appears in About the role and again in responsibilities list. We'll keep only one occurrence (maybe in responsibilities). Also "Performs special projects as assigned by management." appears again later in responsibilities list near the end; we should keep only one. Also "Actively participates in enterprise meetings as management-s proxy as necessary." is there. Now check for any other duplicate: "Provides mentoring and clinical liaison support to appeals staff." appears only once. Now ensure we didn't inadvertently drop any bullet: Let's list responsibilities from text: - Assesses patient's clinical need against established guidelines and standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. - Evaluates the necessity, appropriateness and efficiency of medical services and procedures by inpatient facilities. - Performs review of medical records and prepares medical records for review by Medical Director as appropriate. - Investigates and resolves complicated appeals, coordinating with legal department as necessary and handles appeals concerning pre existing conditions. - Investigates and resolves high priority cases involving DOBI and Executive inquiries. - Prepares and presents appeals to Appeals Committee in accordance with criteria including coordination with independent URO. - Conducts presentations of appeals process to internal customers and works with Delegate and Vendor Oversight to assist vendors in establishing procedures to ensure their appeals process complies with requirements. - Plans appropriate allocation of resources to provide quality patient care in the most cost effective manner. - Documents accurately and comprehensively based on the standards of practice and current organization policies. - Interacts and communicates with facilities, physicians and or members/families, either telephonically and or on site striving for continuity and efficiency as the member is managed along the continuum of care. - Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. - Facilitates the external review process with the IURO and IRO. - Provides 24/7 on call appeal support as scheduled. - Actively participates in enterprise meetings as management-s proxy as necessary. - Performs special projects as assigned by management. - Appeals Resolution RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. We moved the last to Schedule. Now ensure we didn't miss any: "Performs special projects as assigned by management." appears also in About the role; we removed duplicate. Now check Knowledge list: from