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 guidelines and regulatory standards, including NCQA, URAC, and NJ/Federal regulations.

• Offer mentorship and clinical liaison support to the appeals team.

• Evaluate patients’ clinical needs against established guidelines and standards for inpatient care levels and duration of stay.

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

• Review medical records and prepare documentation for Medical Director review as necessary.

• Investigate and resolve complex appeals, collaborating with the legal department when required, including appeals related to pre-existing conditions.

• Address high-priority cases involving DOBI and Executive inquiries.

• Prepare and present appeals to the Appeals Committee, coordinating with independent URO.

• Educate internal stakeholders about the appeals process and assist Delegate and Vendor Oversight with vendor procedures.

• Strategically plan resource allocation to ensure quality patient care in a cost-effective manner.

• Maintain accurate and comprehensive documentation in accordance with practice standards and organizational policies.

• Communicate with facilities, physicians, members, and families both telephonically and on-site to promote continuity and efficiency of care.

• Assess care by problem-solving, analyzing variances, and engaging in quality improvement initiatives.

• Facilitate the external review process with IURO and IRO.

• Provide scheduled on-call appeal support 24/7.

• Participate in enterprise meetings as a representative of management when necessary.

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

• Undertake special projects as assigned by management.

⛳️ Requirements

• High School Diploma or GED is required.

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

• Minimum of 2 years of clinical experience is required.

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

• A Registered Nurse License is required.

• Requires a working knowledge of utilization management principles.

• Must possess knowledge of health care contracts and benefit eligibility criteria.

• Familiarity with hospital structures and payment systems is required.

• Excellent oral and written communication skills are essential.

• Ability to thrive in a high-volume work environment with moderate supervision is necessary.

• Capability to apply an understanding of business fundamentals and manage administrative expenses in daily decision-making is required.

• Proficiency in using a personal computer and relevant software is needed.

• Strong negotiation skills with a proven ability to convert prospects to clients, along with persuasive skills with carriers.

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

• Ability to convey highly technical information to individuals with less technical expertise.

• Commitment to professional and ethical business practices, adherence to company standards, and dedication to personal and professional growth.

• Proven time management skills with the ability to juggle multiple priorities, deliver timely and accurate outputs with a customer service focus, and respond with urgency.

• Ability to work in a production-oriented environment.

• Demonstrated sound judgment and strong problem-solving capabilities.

• Proven ability to ask probing questions and gather thorough and relevant information.

• Client service orientation with a strong ability to empathize.

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

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous Paid Time Off (PTO)

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement