Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.
About the Role
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
What You'll Do
- 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.
What You Bring
Education/Experience
- High School Diploma/GED required.
- Bachelor degree in health care management preferred or relevant experience in lieu of degree.
- Requires 2 years clinical experience.
- Requires 3 years experience in the health care delivery system/industry.
Additional licensing, certifications, registrations
- Requires a Registered Nurse License.
Knowledge
- Specialized knowledge/skills: 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.
Skills & Abilities
- 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.
At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you!
Salary Range
$79,100 - $105,945
This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
Disclaimer
Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.