New Jersey Licensed Appeals Analyst RN

Job Summary

Responsible for managing Utilization Management medical appeal cases, the full-time remote New Jersey Licensed Appeals Analyst RN will ensure compliance with regulatory guidelines, mentor appeals staff, and conduct reviews of medical records while providing 24/7 on-call support as scheduled.

Key responsibilities

• Assess patients' clinical needs against established guidelines to determine the appropriateness of inpatient care
• Investigate and resolve complicated appeals, coordinating with legal departments as necessary
• Prepare and present appeals to the Appeals Committee and conduct presentations on the appeals process to internal stakeholders

Required qualifications

• High School Diploma/GED required; Bachelor's degree in health care management preferred or relevant experience in lieu of degree
• 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