Overview
Remote
Depends on Experience
Contract - W2
Job Details
Utilization Management Appeals Nurse | 2 years’ experience | Remote | Contract
Walker Healthforce is seeking a Utilization Management Appeals Nurse with 2 years of experience to support a healthcare client based out of New Jersey. This is a 6-month contract opportunity.
START DATE: 6/1/2025
HOURS/SCHEDULE: 8am-5pm EST Monday- Friday
WORKER TYPE: W2
CORE REQUIREMENTS:
ADDITIONAL REQUIREMENTS:
WE CONSIDER IT A BONUS IF YOU ALSO HAVE:
JOB RESPONSIBILITIES:
WHAT WE OFFER:
WHY WORK WITH WALKER?
Contact our Recruiting Team today to experience the Walker Healthforce difference!
ABOUT US:
Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!
We are an Equal Opportunity Employer committed to a culturally diverse workforce. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status.
#IND1
Walker Healthforce is seeking a Utilization Management Appeals Nurse with 2 years of experience to support a healthcare client based out of New Jersey. This is a 6-month contract opportunity.
START DATE: 6/1/2025
HOURS/SCHEDULE: 8am-5pm EST Monday- Friday
WORKER TYPE: W2
CORE REQUIREMENTS:
- Minimum of two (2) years clinical experience
- 3 - 5 years of experience with a background in either Utilization Management, Prior Authorization – Medical Surgical (Inpatient or Outpatient), Complex Case Management w/ exposure to UM, Concurrent or Retrospective Medical Policy Review
- Active Unrestricted RN License NJ or Compact
- Associate or bachelor’s degree (or higher) in nursing and/or a health-related field OR accredited diploma nursing school
- Technology Savvy – systems including Care Radius, Outlook, Teams, OneNote, Microsoft Suite
- Proficient in review and investigation of a Utilization Management appeal. This includes understanding of regulations that guide our practice
- Proficient with navigating Utilization Management policies and clinical guidelines
ADDITIONAL REQUIREMENTS:
- Must be located New Jersey, New York, Pennsylvania, Delaware, or Connecticut
WE CONSIDER IT A BONUS IF YOU ALSO HAVE:
- Experience with Medicare, Medicaid and/or DSNP programs
- Familiarity interpreting Milliman Care Guidelines MCG guidelines, CMS Guidelines and Care Radius platform exposure
JOB RESPONSIBILITIES:
- 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.
- Completes other assigned functions as requested by management.
WHAT WE OFFER:
- Competitive compensation package
- Weekly pay via Direct Deposit
- Medical, Dental & Vision available
- 401k options
WHY WORK WITH WALKER?
- Access to our top ranked team of recruiting and placement specialists
- Continuous, one-on-one support from a dedicated engagement manager
- Professional resume development and interview preparation
Contact our Recruiting Team today to experience the Walker Healthforce difference!
ABOUT US:
Walker Healthforce is known as the dominant force of performance, precision, expertise, and integrity in the healthcare consulting community! As a certified WMBE, we provide end-to-end healthcare IT and clinical solutions to hospitals, health systems, and payer organizations, including Fortune 100 firms nationwide. We are healthcare experts, we’re custom not commodity and we’ve been exceeding expectations for nearly 20 years. Join forces with us to experience unparalleled results today!
We are an Equal Opportunity Employer committed to a culturally diverse workforce. All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status.
#IND1
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