Description
SHIFT: Day Job
SCHEDULE: Full-time
Sign-On Bonus: To be offered to selected candidate
Job Title: Remote Nurse Appeals Location: Remote/Work From Home (Considering candidates who are within 1-hour drive of an Anthem (Pulse Point) location and be able to commute to the office if necessary).*
*Selected candidate must ensure work at home office is in a dedicated private and secure room adhering to HIPPA compliance regulations.
Business Hours: 8:00am-8:00pm Est. Shift Hours: 8-hour shift /40-hour workweek within business hours indicated, including holidays and weekends on a rotational basis.**
**This is not a flex hour role. Desired hours must be discussed with Hiring Manager.
Training/Orientation Schedule: Mon-Friday (8:00am-5:00pm Est.) - about 3-4 months.
Be part of an extraordinary team! We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
How you will make an impact: The Nurse Appeals role is responsible for investigating and processing medical necessity appeals requests 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 directors, consultants, and other external reviews.
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.
Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
Qualifications
Minimum Requirements:
Requires a minimum of 2 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 residing state or territory of the United States required.
Preferred Skills, Capabilities and Experiences:
AS or BS in Nursing preferred.
Case management, or Nurse Appeals experience is highly desirable =.
Medicaid or Medicaid experience highly desirable.
Skilled Nursing / Long term care is preferred
Previous experience in insurance is highly desirable.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Anthem approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World's Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.
REQNUMBER: PS74172-Ohio
