Appeal Analyst RN

A healthcare organization in New Jersey is actively seeking a driven Appeal Analyst Nurse (RN) to join their staff in a remote capacity. In this role, the Appeal Analyst Nurse (RN) prepares and presents appeals to Provider Appeals Committee in accordance with criteria including coordination with independent URO.

Responsibilities

The Appeal Analyst Nurse (RN):

• 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
• 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

Qualifications

• Active New Jersey State Registered Nurse license
• Associate's degree
• 2+ years of professional experience
• Appeals experience

Desired skills

• Bachelor's degree
• Utilization Management and Risk Management experience
• Experience in Behavioral Health-related roles
• CareRadius experience