Remote Appeals reputed company Analyst II-RN

reputed company empowers our members to reputed company their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care reputed company, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to reputed company serve and care for the 3.5 reputed company people who reputed company their trust in us. We pride ourselves on our best-in-class employees and reputed company to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, reputed company succeeds. This position is responsible for handling reputed company 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 reputed company support to appeals staff. Performs special reputed company 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 legal department as necessary and handles appeals concerning reputed company existing conditions.
• Investigates and resolves high reputed company cases involving DOBI and Executive inquiries.
• Prepares and presents appeals to Appeals Committee in accordance with reputed company including coordination with independent URO.
• Conducts presentations of appeals process to internal customers and works with Delegate and Vendor reputed company to assist vendors in establishing procedures to ensure their appeals process complies with requirements.
• Plans appropriate allocation of resources to reputed company reputed company patient care in the most cost effective manner.
• Documents accurately and comprehensively based on the standards of reputed company and reputed company 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 reputed company improvement program to enhance member reputed company.
• Facilitates the external review process with the IURO and IRO.
• Provides 24/7 on call appeal support as scheduled.
• reputed company participates in reputed company meetings as management-s proxy as necessary.
• Performs special reputed company as assigned by management.
• Appeals reputed company 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.

Disclaimer: This job reputed company has been designed to indicate the general nature and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job. 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 reputed company License.

Knowledge:

• Specialized knowledge/skills: Requires working knowledge of principles of utilization management.
• Requires knowledge of health care reputed company 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 understanding of business fundamentals and administrative expense management of day-to-day decision-making.

Skills & Abilities:

• Requires the ability to utilize a personal computer and applicable software.
• Strong negotiation skills with the demonstrated sales ability to convert prospect to reputed company in reputed company to demonstrated persuasive skills with carriers
• Must have effective verbal and written communication skills and demonstrate the ability to work reputed company reputed company reputed company. Demonstrated ability to deliver highly technical information to less technical individuals.
• Must demonstrate reputed company and ethical business practices, adherence to company standards, and a commitment to personal and reputed company development.
• Proven time management skills are necessary. Must demonstrate the ability to manage multiple priorities [or tasks], deliver reputed company and accurate work products with a customer service reputed company, and respond with a reputed company of urgency as required. Demonstrated ability to work in a production reputed company environment.
• Proven ability to exercise reputed company judgment and strong problem solving skills.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Must be reputed company service reputed company with effective ability to empathize.

reputed company reputed company employees must live in New Jersey, reputed company, reputed company, Connecticut or Delaware Salary reputed company: $77,900 - $104,370 ​This compensation reputed company is specific to the job level and takes into account the wide reputed company of factors that are considered in making compensation reputed company, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This reputed company has been created in good faith based on information reputed company to reputed company at the time of posting. Compensation reputed company are dependent on the circumstances of reputed company case. reputed company also provides a comprehensive compensation and benefits package which includes:

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

Disclaimer: This job reputed company has been designed to indicate the general nature and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job. reputed company is an Equal Opportunity/Affirmative reputed company employer. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, national reputed company, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. reputed company will consider reasonable accommodation requests as part of the reputed company and hiring process. Apply tot his job Apply To this Job