New Jersey Licensed Medical Policy Analyst

Job Summary

Responsible for medical policy determination of claims and cases, the part-time New Jersey Licensed Medical Policy Analyst will analyze medical records and claims to ensure compliance with clinical guidelines and medical policies while working remotely.

Key responsibilities

• Perform reviews of post-service medical necessity and appealed claims for compliance with medical policy and plan benefits
• Prepare cases for Medical Director and outside consultant review and provide timely responses to inquiries related to claims pending for medical review
• Communicate opportunities for developing or revising medical policies based on case review outcomes and manage assigned inventory through completion

Required qualifications

• High School Diploma or GED required
• Minimum of 3 years' clinical nursing experience
• Knowledge of laws, regulations, and policies relevant to the organization
• Ability to manage multiple priorities in a production-focused environment
• Demonstrated sound judgment and problem-solving skills