Vacancy expired!
Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At National Government Services (NGS), an independent subsidiary of Anthem, Inc. and one of the largest Medicare contractors in the country, it’s a powerful combination. It’s 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. 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:
Conducts investigations and reviews of member and provider grievances and appeals.
Assesses the necessity and reasonableness of the items supplied in a valid claim using medical policy and other materials.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
Outpatient or surgical experience helpful.
Strong computer skills helpful.
Experience with MCSDT or other CMS mainframe system helpful.
Prior experience with claim review helpful.
This position may work from our Indianapolis, IN or Syracuse, NY offices. Qualifications
Current unrestricted RN license required. Two (2) years’ clinical experience.
Excellent communication skills, demonstrates prioritization, problem solving, and organization skills.
Strong computer skills, including Microsoft Office proficiency.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.REQNUMBER: PS35185
Vacancy expired!