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Nurse Appeals

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Location: Cerritos, CA
Job Family: Medical
Req #: PS30107
Date Posted: Jun 26, 2020

Description

SHIFT: Day Job

SCHEDULE: Full-time

 
 
 
 

Your Talent. Our Vision.  At CareMore, a proud member of the Anthem, Inc. family of companies specializing in providing senior Americans a complete and pro-active health care experience, it’s a powerful combination.  It’s 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. 

 

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 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. 

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 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.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.


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