Description
SHIFT: Day Job
SCHEDULE: Full-time
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.
Monday to Friday 8am - 5pm. Must have your CA RN license and reside in the state of CA. 100% work from home.
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 reviews.
- 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.
Qualifications
Requirements:
- 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 California RN license to practice as a health professional within 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
