Company Overview
The Judge Group is an international leader in business technology consulting, talent solutions, and learning and development. With over 30 locations across the U.S., Canada & India, Judge is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government, aerospace & defense, manufacturing, and technology & telecommunications. Judge has always been committed to doing what’s right – for our colleagues, our client partners, and our communities. At Judge, we cultivate an inclusive environment that empowers our employees to produce their best work. As a family-owned business, we’re not just a high-performing team, but a high-performing family. Through building relationships and our cultural commitment to caring, we support one another. Our People-powered Business Solutions Talent & Executive Search From temporary consultants to C-level executives, The Judge Group works across all industries and domains to find exceptional talent. IT Consulting We take an end-to-end approach to technology, working alongside your teams to design, build, implement, and manage all of your organization’s IT resources. Our enterprise IT consulting services and solutions encompass the full technology spectrum, from IT and business transformation, and cloud migration to digital strategies and execution, strategic roadmaps and delivery, process and governance optimization, and IT infrastructure and wireless solutions. Learning Solutions As a leading provider of corporate learning services for companies of all sizes and industries, Judge employs a strategic approach to learning that meets organizational training goals while strengthening business outcomes. Regardless of when, where, or how you want to train your team, our solutions are engineered to engage and support employees throughout their learning journey.
About the job
Job Title: Remote UM Appeals RN
- Location: NJ, PA, NY, CT, MD (Remote)
- Schedule: Mon-Fri, 8 AM – 5 PM EST
- MUST have a NJ RN license
Requirements:
- Must reside in NJ, PA, NY, CT, or MD
- 100% remote position with equipment provided
- Active RN license in NJ
- Experience in UM Appeals for a health plan
Job Description:
- Assesses patient’s clinical need against established guidelines and/or 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 provided.
- Coordinates and assists in implementation of plan for members.
- Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
- Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.
- Monitors patient’s medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.
- Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.
- Encourages member participation and compliance in the case/disease management program efforts.
- Documents accurately and comprehensively based on the standards of practice and current organization policies.
- Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.
- Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.
- Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.
Qualifications:
- Active, unrestricted RN license in NJ or a Compact State
- Experience with health plan appeals; knowledge of UM Pharmacy appeals preferred
- Proficient in navigating UM policies and clinical guidelines
- Technologically savvy, able to navigate multiple systems and type 80 WPM
- Familiarity with Care Radius, Outlook, Teams, OneNote, and Microsoft Suite is a plus
- Ability to thrive in a fast-paced environment
- Strong presentation skills for clinical information
- Quick, sound clinical judgment to maintain turnaround times
- Proficient in UM appeal review and investigation, with an understanding of relevant regulations
How to Apply:
APPLY