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Anthem, Inc. Nurse Appeals Ld in New York, New York

Description

SHIFT: Day Job

SCHEDULE: Full-time

Empire BlueCross BlueShield , a proud member of the Anthem, Inc. family of companies, has been serving our communities for over 85 years.  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. Empire’s commitment to inclusion and diversity makes us a stronger organization. Our culture is essential to attracting talent that understands and connects with our consumers. It creates spaces where different perspectives and experiences are valued; it lets us develop innovative thinking and unifies our associates behind our mission—to materially and measurably improve the whole health of all New Yorkers and make healthcare simpler. Empire’s Whole Health proposition is committed to protecting an individual’s complete health and wellness. Our inclusivity is the foundation to serve and support our diverse New York communities.

Position: Nurse Appeals Lead

Responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers and provide leadership and work direction to other appeals staff.

Primary duties may include, but are not limited to:

  • Conducts investigations and reviews of member and provider grievances and appeals.

  • Reviews prospective 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.

  • Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.

Qualifications

Requires minimum of 5 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.

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: PS58836

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