Appeals Resolution Analyst II-RN

Horizon Blue Cross Blue Shield of New Jersey•Hopewell, NJ

About The Position

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

Requirements

High School Diploma/GED required.
Requires 2 years clinical experience.
Requires 3 years experience in the health care delivery system/industry.
Requires a Registered Nurse License.
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 understanding of business fundamentals and administrative expense management of day-to-day decision-making.
Requires the ability to utilize a personal computer and applicable software.
Strong negotiation skills with the demonstrated sales ability to convert prospect to client in addition to demonstrated persuasive skills with carriers
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.
Demonstrated ability to deliver highly technical information to less technical individuals.
Must demonstrate professional and ethical business practices, adherence to company standards, and a commitment to personal and professional development.
Proven time management skills are necessary.
Must demonstrate the ability to manage multiple priorities [or tasks], deliver timely and accurate work products with a customer service focus, and respond with a sense of urgency as required.
Demonstrated ability to work in a production focused environment.
Proven ability to exercise sound judgment and strong problem solving skills.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be client service focused with effective ability to empathize.

Nice To Haves

Bachelor degree in health care management preferred or relevant experience in lieu of degree.

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 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.