Remote
Anthem, Inc.

RN – Nurse Appeals or Senior $3K Sign On Bonus (Eagan, MN, Remote or Any Anthem Office) – PS9431

Eagan, Minnesota, United States

United States

Medical

PS13488

Your Talent. Our Vision. At Anthem, Inc., the Government Business Division is focused on serving Medicaid, Medicare and uninsured individuals. Our commitment and focus on government health programs is the foundation upon which we’re creating better care for our members, greater value for our customers and better health for our communities. Join us and together we will drive the future of health care.

Join one of the fastest growing businesses in a company with the largest and most successful Medicaid business in the nation. The associate in this position will be supporting members enrolled in the Minnesota Medicaid Program.

Position can be located in Eagan, MN Office, Any Anthem Office, or Remote/Work-At-Home

Medicaid RN Nurse Appeals / Appeals Sr. (Job Family)

$3,000 Sign-On Bonus Available!!!

Please note: This position may be filled at either the Nurse Appeals or Nurse Appeals Senior Level. The manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.

RN Nurse Appeals:

The Nurse Appeals is responsible for investigating and processing and 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 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 written correspondence to providers, members, and regulatory entities. Utilize 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.

RN – Nurse Appeals Senior:

The Nurse Appeals Senior is 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.

Qualifications:

  • Requires 2-4 years or more 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 the state of Minnesota required.
  • Appeals experience highly desired.
  • Utilization Management experience highly desired.
  • Medicaid experience preferred.
  • Managed Care experience preferred.
  • Critical Care (ER/ICU) experience very helpful.
  • Minimum of 5 years of direct-care experience strongly preferred.
  • AS/BS in Nursing preferred.

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.