Nurse Appeals or Nurse Appeals Sr.
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Location: Rancho Cordova, CA
Job Family: Medical
Req #: PS36654-Rancho%20Cordova-Rancho%20Cordova
Date Posted: Dec 17, 2020
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Description
SHIFT: Day JobSCHEDULE: 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 benefits companies and a Fortune Top 50 Company.
- Candidate must reside within a reasonable commuting distance to a California Anthem office, preferably up to 60 miles one way.
- Can be filled as a Nurse Appeals or Nurse Appeals Sr. Nurse Appeals
- Responsible for investigating and processing the most complex grievances and appeals requests from members and providers. Primary duties may include, but are not limited to:
- Conducts investigations and reviews of member and provider grievances and 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 time frames.
- Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
- Generates appropriate written correspondence to providers, members, and regulatory entities.
- Serves as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.
Qualifications
Nurse Appeals- 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 within California.
- AS/BS in Nursing preferred.
Nurse Appeals Sr.
- Requires 4 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 California.
- AS/BS in Nursing preferred.
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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