Anthem, Inc. Nurse Appeals in Hingham, Massachusetts
SHIFT: Day Job
Your Talent. Our Vision. At 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.
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.
The work schedule for this position is Tuesday thru Saturday with Sunday rotation, 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 Monday thru Friday, for approximately 3 – 4 months, once independent with expedited case reviews will transition to hired work schedule which includes Saturday as a regular work day, with Sunday & holiday rotation.
The position will allow to work from home (W@H) as of the start date, however, the associate must be willing to go to an office location as necessary, and must live within 1 hour driving distance from an Anthem/Amerigroup office. 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. Training is virtual and will last approximately 3 months.
Requires 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 wihtin the scope of licensure in applicable state(s) or territory of the United States required.
AS/BS in Nursing preferred.
For URAC accredited areas the following applies: Requires 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. Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.
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