Nurse Appeals Sr
Company: Anthem, Inc.
Posted on: May 3, 2021
SHIFT: Day Job
Your Talent. Our Vision. At Healthy Blue, a strategic alliance
of Blue Cross NC and Amerigroup, an Anthem Inc. company, 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 benefits companies and a Fortune Top 50 Company.
This position may be remote within NC or neighboring states and
will be responsible for overseeing a designated region of NC. Home
office location: 11000 Weston Parkway, Cary, NC. Candidates must
reside in the state of NC or neighboring states (SC, VA, TN).
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
- 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
- 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 NC, SC, VA, or TN
- AS/BS in Nursing preferred.
- Appeals experience highly desired.
- 2+ years of UM experience required.
- Requires strong oral, written and interpersonal communication
skills, problem-solving skills, facilitation skills, and analytical
- Proficiency with MS Office products required.
- Experience researching Medicaid clinical guidelines
- Good computer and typing skills required.
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
Anthem, Inc. is ranked as one of America's Most Admired
Companies among health insurers by Fortune magazine and has been
named a 2019 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.
Keywords: Anthem, Inc., Annandale , Nurse Appeals Sr, Other , Annandale, Virginia
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