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Appeal Analyst RN # 26-21019

US Tech Solutions

Role overview

Qualifications

  • Bachelor's degree in nursing or Equivalent Experience
  • Active New Jersey Registered Nurse License

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

Key facts

Hard skills

Utilization Management Medical Jurisprudence Clinical Assessments Nursing

Other skills

  • Communication
  • Problem Solving
  • Analytical Skills

About the company

US Tech Solutions logo

US Tech Solutions

Staffing & Recruiting

USTECH SOLUTIONS is the largest privately owned diversity workforce partner with a global footprint. For 20+ years, we have partnered with leading MSPs and some of the world’s largest enterprises to deliver a flexible workforce. We serve Fortune 500 giants and growing businesses alike, reinventing the role of humans in a digital workforce. ‘Reinventing Human’ is about connecting you with top talent and seamlessly integrating new hires into your programs through our next gen AI powered Talent platforms. As the largest private diversity supplier in the US, we champion inclusion and unlock hidden potential. We work with leading MSPs and are a trusted strategic partner to the world’s top brands. At USTECH SOLUTIONS, we're inverting the talent hiring pyramid by offering a range of solutions from curated talent pools, workforce management services, and IT services resourcing to IC compliance. Our legacy and close affinity to the computing industry has equipped us with the expertise and vision to provision AI platform solutions that help organizations to innovate faster. Considering Statement of Work? Meet US Tech Digital (ustechdigital.com). We're helping businesses achieve digital leadership through our tailored SOW solutions, utilizing market-leading technology products and our proprietary in-house developed platform solutions. Explore our full range of services and solutions by visiting our website: ustechsolutions.com

Company details

Company typeLarge
IndustryStaffing & Recruiting
Company size1001 - 5000

Links

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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 www.ustechsolutions.com .

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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