Appeals Resolution Analyst II – RN

Horizon Connect @ Wall BCBSNJ

. Handle all Utilization Management medical appeal cases.

Posted 9/17/2026full-timeRemote • Connecticut • United StatesMid-LevelSenior💰 $79,100 - $105,945 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in Utilization Management and clinical assessment, ensuring compliance with NCQA, URAC, and regulatory standards. Proficient in managing medical appeals, mentoring staff, and delivering effective communication across healthcare teams.

Highest-signal resume keywords

Utilization ManagementRegistered Nurse LicenseClinical ExperienceHealth Care Delivery System KnowledgeNegotiation Skills

ATS Keywords

Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills

Clinical AssessmentMedical Record ReviewAppeals Process ManagementQuality Improvement ParticipationResource Allocation Planning

Soft Skills

Effective CommunicationProblem-SolvingTime ManagementClient Service FocusTeam Collaboration

Tools & Technologies

Personal ComputerApplicable Software

Certifications & Qualifications

Registered Nurse License

Industry Keywords

NCQAURACHealth Care ContractsBenefit EligibilityHospital StructuresPayment Systems

About the role

Key responsibilities & impact

Handle all Utilization Management medical appeal cases.
Ensure timeliness guidelines and regulatory requirements are met, including NCQA, URAC, and NJ/Federal regulations.
Provide mentoring and clinical liaison support to appeals staff.
Assess patients’ clinical needs against established guidelines and standards for inpatient level of care and length of stay.
Evaluate the necessity, appropriateness, and efficiency of medical services and procedures provided by inpatient facilities.
Review medical records and prepare records for Medical Director review as appropriate.
Investigate and resolve complicated appeals, coordinating with the legal department as necessary, including appeals concerning pre-existing conditions.
Investigate and resolve high-priority cases involving DOBI and Executive inquiries.
Prepare and present appeals to the Appeals Committee, coordinating with independent URO.
Present the appeals process to internal customers and assist Delegate and Vendor Oversight with vendor procedures.
Plan resource allocation to provide quality patient care cost-effectively.
Document accurately and comprehensively according to standards of practice and organizational policies.
Communicate with facilities, physicians, members, and families telephonically or on site to support continuity and efficiency of care.
Evaluate care by problem-solving, analyzing variances, and participating in quality improvement programs.
Facilitate the external review process with IURO and IRO.
Provide scheduled 24/7 on-call appeal support.
Participate in enterprise meetings as management’s proxy when necessary.
Work specified weekends and holidays as required by regulatory and accrediting standards.
Perform special projects as assigned by management.

Requirements

What you’ll need

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.
Requires a Registered Nurse License.
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.
Requires the ability to apply an understanding of business fundamentals and administrative expense management of day-to-day decision-making.
Requires the ability to utilize a personal computer and applicable software.
Strong negotiation skills with demonstrated sales ability to convert prospect to client, in addition to persuasive skills with carriers.
Effective verbal and written communication skills and ability to work well within a team.
Ability to deliver highly technical information to less technical individuals.
Professional and ethical business practices, adherence to company standards, and commitment to personal and professional development.
Proven time management skills and ability to manage multiple priorities, deliver timely and accurate work products with a customer service focus, and respond with urgency.
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.
Client service focus with effective ability to empathize.
Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement