Appeals Resolution Analyst II / RN
Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
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 What You'll Do
-
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.
What You Bring
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:
-
Specialized knowledge/skills: 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