Nurse Appeals – I or Senior at Anthem, Inc.
Nurse Appeals I/Sr – Remote
- Iowa, United States
- Requisition #PS27456
Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, 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.
Can reside anywhere in the US. However, must have a Compact RN License if not an Iowa resident and be able to work Mon-Fri 8am-5pm CST.
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 regulatory timeframes.
- 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 initiatives.
- Requires 2-4 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 applicable state(s) or territory of the United States required. AS/BS in Nursing preferred.
- If not an Iowa resident, must have a Compact RN License.
- For NCQA accredited areas, the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
- Must be able to work 8:00am-5:00pm CST schedule.
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