Anthem, Inc. Nurse Appeals in Denver, Colorado
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
Nurse Appeals (Medicare Appeals and Grievance) - Mason, OH
Due to COVID-19, temporary adjustments have been made to permit new hired associate to work from home as of their start date, however, the associate must be willing to go to an office location as necessary, and must have a dedicated room or location in home to be set-up as a private, secure location to allow for compliance with HIPAA regulations. Training is virtual and will last approximately 3 months.
This position is a second shift schedule. Candidates must be available to work an 8-hour shift between the hours of 8am and 8pm EST, Tuesday through Saturday, including holidays on a rotation. Saturday is a scheduled work day and candidates must be available to work Sundays on a rotation. Current work-from-home Anthem associates may continue to work remotely, but in-office Anthem associates will continue to work from the office, and external candidates would work from the Mason, OH office
The Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers.
Primary duties may include, but are not limited to:
Conducts investigations and reviews of member and provider medical necessity appeals.
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
Extrapolates and summarizes medical information for the medical director, consultants and other external review.
Prepares recommendations to either uphold (deny) or approve appeals and forwards to the Medical Director for determination.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
Generates written correspondence to providers, members, and regulatory entities.
Utilizes leadership skills and serves as a subject matter expert for appeals/expedited grievances issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
Current active unrestricted RN license to practice as a health professional within the scope of licensure in Ohio or the state in which you live required.
AS/BS in Nursing preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Prior utilization management and/or medical chart review experience preferred.
Prior experience coordinating member care is helpful.
Critical thinking skills are required.
Experience with GBD Facets, ACMP, and WMDS is preferred.
EMR experience is required.
Experience working with Medicare/Medicaid and knowledge of their regulations is strongly preferred
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.