, Virginia

Description

SHIFT: Day Job

SCHEDULE: Full-time

The Nurse Appeals is responsible for investigating and processing and 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 medical director, consultants and other external review.
  • Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  • 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.
  • Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.

Please Note -The work schedule for this position is Tuesday thru Saturday with Sunday rotation, business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8 hour shift between those hours, including holidays on a rotational basis.

Training is Monday thru Friday, for approximately 3 – 4 months, once independent with expedited case reviews will transition to hired work schedule which includes Saturday as a regular work day, with Sunday & holiday rotation.


 

Qualifications

Qualifications - External

  • Requires 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 wihtin the scope of licensure in applicable state(s) or territory of the United States required.
  • AS/BS in Nursing preferred.
  • For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

, Virginia

If you’re a reserve or veteran member of the military, we foster a welcoming environment that’s dedicated to honoring your service and helping you achieve your career goals. Veterans of Anthem — one of our Business Resource Groups — partners with our Talent Acquisition teams to maximize career offerings for you and your family members, striving to help you transition to civilian service and grow your career at the same time. 

Join Anthem's Military and Veteran Talent Network: https://anthemcareers.ttcportals.com/pages/military 

WE ARE HIRING

Anthem, Inc. is currently seeking military veterans and military spouses with operations experience.  Whether your experience is hands-on as an operational specialist or in operational leadership, Anthem wants to have an impact on your career and professional growth by speaking with you about their career opportunities.

If you are interested in learning more, check out Anthem's current open positions to the right for more information and to apply today!

Not sure where to start?  Send RecruitMilitary Success Manager, Taylor Groves, your questions at taylor.groves@recruitmilitary.com 

 

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