Job Details

ID #3700241
State Illinois
City Westchester
Full-time
Salary USD TBD TBD
Source Anthem, Inc
Showed 2020-04-04
Date 2020-04-05
Deadline 2020-06-04
Category Et cetera
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Nurse Appeals - PS34350

Illinois, Westchester 00000 Westchester USA

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 benefits companies and a Fortune Top 50 Company.Nurse Appeals is responsible for investigating and processing medical necessity requested appeal received 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 entities.

Prepares recommendations to either uphold (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.

Ensures that appeals are resolved timely to meet regulatory timeframes.

Documents and logs appeal 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 of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.

Qualifications Qualifications:

Requires 3 – 5 years of clinical experience as a Registered Nurse.

Current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States required.

At least 2 years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting is strongly preferred.

AS/BS in Nursing preferred

Experience researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy preferred.

Experience reviewing claims and researching CPT codes or ICD-9 codes preferred.

External selected candidates must either live at least an hour or less from the office, willing to relocate, or work from the Mason Ohio office for a minimum of 6 months.

Schedule: The work schedule for this position is Tuesday through Saturday with Sunday rotation (2nd shift), business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8 hour shift between those hours, including holidays on a rotational basis.Training: This position requires on-site training in our Mason, OH office. However, due to Coronavirus this position can offer virtual training until the office reopens. Once the office opens, this position would return to on-site for the duration of the training period.Training is Monday thru Friday, for approximately 3 – 4 months, once independent with expedited case reviews will transition to 2nd shift work schedule which includes Saturday as a regular work day, with Sunday rotation.To transition to work@home, must have a dedicated room or location in home to be set-up as a private, secure location to allow for compliance with HIPAA regulations.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: PS34350

Vacancy expired!

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