Nurse Appeals Or Nurse Appeals Sr.

Anthem, Inc. Rancho Cordova , CA 95741

Posted 2 weeks ago

Description

SHIFT: Day Job

SCHEDULE: Full-time

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 need to work out of one of the following office locations. Please note due to the current pandemic, this position has been approved to work remote until the offices reopen.

  • Thousand Oaks, CA

  • Rancho Cordova, CA

  • Woodland Hills, CA

  • Working remote is an option once training and performance requirements are met.

  • Can be filled as a Nurse Appeals or Nurse Appeals Sr. Nurse Appeals

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 time frames.

  • 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

Nurse Appeals

  • 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 within California.

  • AS/BS in Nursing preferred.

Nurse Appeals Sr.

  • Requires 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 California.

  • 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.

icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Nurse Appeals Or Nurse Appeals Sr California Ps36654

Anthem, Inc.

Posted 2 months ago

VIEW JOBS 9/9/2020 12:00:00 AM 2020-12-08T00:00 Description SHIFT: Day Job SCHEDULE: Full-time 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 need to work out of one of the following office locations. Please note due to the current pandemic, this position has been approved to work remote until the offices reopen. * Thousand Oaks, CA * Rancho Cordova, CA * Woodland Hills, CA * Working remote is an option once training and performance requirements are met. * Can be filled as a Nurse Appeals or Nurse Appeals Sr. Nurse Appeals 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 time frames. * 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 Nurse Appeals * 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 within California. * AS/BS in Nursing preferred. Nurse Appeals Sr. * Requires 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 California. * 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. Anthem, Inc. Rancho Cordova CA

Nurse Appeals Or Nurse Appeals Sr.

Anthem, Inc.