Appeals Resolution Analyst II / RN

About the Role

This position is responsible for handling all Utilization Management medical appeal cases. Ensures that timeliness guidelines are met and appeals are 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.

Responsibilities

• 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 the 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 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 RNs 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.

Requirements

• High School Diploma/GED required.
• Bachelor's degree in healthcare management preferred or relevant experience in lieu of degree.
• Requires 2 years of clinical experience.
• Requires 3 years of experience in the healthcare delivery system/industry.
• Requires a Registered Nurse License.

Qualifications

• Requires working knowledge of principles of utilization management.
• Requires knowledge of healthcare 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 apply an understanding of business fundamentals and administrative expense management in day-to-day decision-making.

Skills & Abilities

• Requires the ability to utilize a personal computer and applicable software.
• Strong negotiation skills with demonstrated ability to convert prospects to clients, in addition to persuasive skills with carriers.
• Effective verbal and written communication skills, with the ability to work well within a team.
• Demonstrated ability to deliver highly technical information to less technical individuals.
• Professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
• Proven time management skills and 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.
• Client service-focused with effective ability to empathize.

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.

Benefits

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

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.