Nurse Appeals

Description

Location: Remote, but must be within 1 hour of an Anthem office. 

To Work@Home, candidate 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.

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 is virtual, Monday thru Friday, for approximately 3 – 4 months, once independent with expedited case reviews will transition to 2^nd shift work schedule which includes Saturday as a regular work day, with Sunday rotation.

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.
• AS/BS in Nursing preferred
• Preferred 2 years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background.
• Prefer experience researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy.
• Prefer experience reviewing claims and researching CPT codes or ICD-9 codes
• External selected candidates must live at least an hour or less from the office or willing to relocate or work from the Mason Ohio office for a minimum of 6 months.

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.