Anthem, Inc RN Nurse Appeals - Nashville, TN, Kentucky & West Virginia - TN RN license Required! in Nashville, Tennessee
RN Nurse Appeals - Nashville, TN, Kentucky & West Virginia - TN RN license Required!
Location: Nashville, Tennessee, United States
Requisition #: PS23916
Post Date: Aug 01, 2019
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and 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 at one of America's leading health benefits companies and a Fortune Top 50 Company.
This position will be work@home or office-based. Work@home associates will work within the Central Region (KY, TN, or WV) and must reside within
an hour of a TN Anthem/Amerigroup office.
This Nurse Appeals role will support the Tennessee Health Plan and may also support other Health Plans within the Central Region. This role is responsible for supporting the development and implementation of quality improvement interventions and audits; investigates and processes 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 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.
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 in the State of Tennessee required.
Experience with Medicaid required (in Managed Care or Health Insurance industry preferred.)
AS/BS in Nursing preferred.
Experience working with Interqual and/or MCG strongly preferred.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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 antheminc.com/careers. An Equal Opportunity Employer/Disability/Veteran.