Appeal Analyst RN # 26-21019

Job Description

Job Description

Duration: 3+ months contract with potential for FTE conversion

Job Description:

• Appeal Analyst RN who will train new hire in the clinical role to complete Utilization Management Appeals and act as an RN I on the team. 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.

Responsibilities:

• Prepares and presents appeals to Provider Appeals Committee in accordance with criteria including coordination with independent URO
• 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.

Education:

• Bachelor's degree in nursing or Equivalent Experience

Licenses:

• Active New Jersey Registered Nurse License

About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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