Appeals Resolution Analyst II – RN

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Manage all medical appeal cases related to Utilization Management.

• Ensure compliance with timeliness standards and regulatory mandates, including NCQA, URAC, and NJ/Federal regulations.

• Provide mentorship and clinical liaison assistance to the appeals team.

• Evaluate patients' clinical requirements against established guidelines and standards for appropriate inpatient care levels and duration of stay.

• Assess the necessity, appropriateness, and efficiency of medical services and procedures provided by inpatient facilities.

• Review medical documentation and prepare records for the Medical Director's assessment as needed.

• Investigate and resolve complex appeals, coordinating with the legal department when necessary.

• Manage appeals regarding pre-existing conditions.

• Investigate and resolve urgent cases involving DOBI and Executive inquiries.

• Prepare and present appeals to the Appeals Committee, including working with an independent URO.

• Educate internal stakeholders about the appeals process.

• Collaborate with Delegate and Vendor Oversight to assist vendors in developing compliant appeals processes.

• Strategically allocate resources to ensure quality patient care in a cost-effective manner.

• Document thoroughly and accurately according to organizational policies and standards of practice.

• Communicate with facilities, physicians, members, and families via phone or in-person.

• Evaluate care quality by problem-solving, analyzing discrepancies, and engaging in quality improvement initiatives.

• Facilitate the external review process with the IURO and IRO.

• Provide on-call appeal support around the clock as scheduled.

• Attend enterprise meetings as a proxy for management when required.

• Work during specified weekends and holidays as mandated by regulatory and accrediting standards.

• Undertake special projects assigned by management.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• A Bachelor's degree in health care management is preferred or relevant experience may be considered in lieu of a degree.

• A minimum of 2 years of clinical experience is required.

• At least 3 years of experience in the health care delivery system or industry is necessary.

• A valid Registered Nurse License is required.

• Familiarity with utilization management principles is essential.

• Understanding of health care contracts and benefit eligibility criteria is needed.

• Knowledge of hospital frameworks and payment systems is important.

• Exceptional oral and written communication abilities are required.

• Capacity to thrive in a high-volume environment with moderate supervision.

• Ability to apply business fundamentals and administrative expense management in daily decision-making.

• Proficiency in using a personal computer and relevant software applications.

• Strong negotiation and persuasive skills are necessary.

• Effective verbal and written communication skills with the ability to collaborate well within a team.

• Capability to convey highly technical information to individuals with less technical knowledge.

• Commitment to professional and ethical business practices, adhering to company standards.

• Demonstrated time management skills are essential.

• Ability to manage multiple priorities, deliver timely and precise work outputs, respond urgently, and maintain a customer service orientation.

• Experience working in a production-focused setting is necessary.

• Sound judgment and strong problem-solving capabilities are required.

• Ability to ask probing questions to gather comprehensive and relevant information.

• Client-service orientation and ability to empathize with others.

• Must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits, including Medical, Dental, and Vision.

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.

• Flexible remote work arrangements.