Appeals Resolution Analyst II – RN

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

📋 Description

• Manage all Utilization Management medical appeal cases while adhering to timeliness guidelines and regulatory standards.

• Evaluate patients' clinical needs against established guidelines and standards for appropriate inpatient care and length of stay.

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

• Review medical records and prepare them for the Medical Director's review as necessary.

• Investigate and resolve complex appeals, including pre-existing condition appeals and high-priority DOBI and Executive inquiries.

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

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

• Strategize resource allocation to ensure high-quality patient care in a cost-effective manner.

• Document information accurately and comprehensively in accordance with practice standards and organizational policies.

• Communicate with facilities, physicians, members, and families via telephone and/or in person 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 IUROs and IROs.

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

• Attend enterprise meetings as management's representative when required.

• Execute special projects assigned by management.

• Work a specified number of weekends and holidays based on regulatory and accrediting body standards and departmental business requirements.

⛳️ Requirements

• High School Diploma/GED is mandatory.

• Bachelor's degree in health care management is preferred, or relevant experience may substitute for the degree.

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

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

• A 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 structures and payment systems is beneficial.

• Exceptional oral and written communication skills are necessary.

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

• Capability to apply 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 and proven sales ability to convert prospects into clients are essential.

• Demonstrated persuasive skills with carriers are necessary.

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

• Ability to convey highly technical information to less technical individuals is important.

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

• Proven time management abilities are required.

• Ability to manage multiple priorities or tasks while delivering timely and accurate work products with a customer service focus is crucial.

• Ability to respond urgently as needed is important.

• Capability to work in a production-focused environment is necessary.

• Proven sound judgment and strong problem-solving skills are essential.

• Ability to ask probing questions and gather thorough, relevant information is required.

• Client-service orientation and the ability to empathize are necessary.

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

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement