Clinical Review Nurse I
DescriptionSHIFT: Day Job
Be part of an extraordinary team
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
National Government Services is a proud member of Anthem's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs.
Shift: Monday - Friday, 8 am - 5 pm Eastern & Central Time Zones.
How you will make an Impact:
Clinical Review Nurses are responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care. This position is also responsible for adapting to a wide variety of medical review topics in Part B appeals. Ability to articulate clearly with other clinicians to include medical doctors, nurses, and support personnel is required. Responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries. Primary duties may include, but are not limited to:
Primary duties may include, but are not limited to:
- Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
- Conducts investigations and reviews of member and provider grievances and appeals.
- Generates appropriate written correspondence to providers, members, and regulatory entities.
- Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
- Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
- Current unrestricted RN license required.
Preferred Skills, Capabilities, and experience:
- BS in nursing preferred.
- Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
- Two (2) years of clinical experience.
- Excellent communication skills, demonstrates prioritization, problem solving, and organization skills.
- Strong computer skills, including Microsoft Office proficiency.
- Outpatient or surgical experience helpful.
- Experience with MCSDT or other CMS mainframe system helpful.
- Prior experience with claim review helpful.
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.