Anthem, Inc. Nurse Appeals Sr in Hialeah Gardens, Florida
SHIFT: Day Job
Your Talent. Our Vision. At Anthem Blue Cross and Blue Shield, a proud member of the Anthem, Inc. family of companies, 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.
Location: Virginia | New York | Pennsylvania | Ohio | Indiana | Kentucky | Florida Role and responsibilities: Investigates and processes 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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to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.
• Minimum of 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 or BS in Nursing preferred. • For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have 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.