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Nurse Appeals

Location: , VA
Job Family: Medical
Req #: PS50233-Virginia
Date Posted: Jun 24, 2021

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.

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