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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…
The Appeals Resolution Analyst II (RN) manages medical appeal cases by assessing clinical necessity against established standards and ensuring regulatory compliance. The role involves coordinating with medical directors, legal teams, and external review organizations to resolve complex coverage disputes.
Reviews medical appeals for a health insurer, ensuring compliance with regulations and clinical appropriateness of care decisions.
Performs internal/external vulnerability scans, assesses risks, and partners with teams to remediate threats across Horizon’s enterprise healthcare environment using tools like Nessus and Qualys.
Registered nurse performs utilization management, assessing patient care against guidelines, coordinating services, and ensuring cost-effective treatment across the continuum of care.
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