New Jersey Licensed Appeals Analyst RN

Job Summary

Managing all Utilization Management medical appeal cases, the full-time New Jersey Licensed Appeals Analyst RN will ensure compliance with regulatory requirements, mentor appeals staff, and perform special projects while working remotely.

Key responsibilities

• Assess patients' clinical needs against established guidelines to determine appropriateness of care and length of stay
• Investigate and resolve complicated appeals, coordinating with legal departments as necessary
• Prepare and present appeals to the Appeals Committee, ensuring adherence to criteria and regulatory standards

Required qualifications

• High School Diploma/GED required; Bachelor's degree in health care management preferred
• 2 years of clinical experience required
• 3 years of experience in the health care delivery system/industry required
• Current Registered Nurse License required
• Working knowledge of principles of utilization management and health care contracts