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Anthem, Inc. Nurse Appeals/Nurse Appeals Sr in Costa Mesa, California

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.

$3,000 Sign on Bonus Offered

Location: Remote in the state of California

Work schedule/hours: Monday - Friday; normal business core hours

This requisition may be filled as Nurse Appeals or Nurse Appeals Senior (hiring level based on experience)

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

The Nurse Appeals Sr is 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 timeframes.

  • 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 Qualifications:

  • 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 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.

Nurse Appeals Sr Qualifications:

  • 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 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.

REQNUMBER: PS56301-California

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