Anthem, Inc. Nurse Appeals Associate in Fort Worth, Texas
SHIFT: Day Job
Your Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, 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.
Work at home, but must be within one (1) hour driving distance to an Anthem/Amerigroup office location. Working from home starts with ensuring that Anthem’s requirements for maintaining confidentiality, ensuring PHI compliance, and network access meets Anthem’s guidelines. To work from home the new associate must confirm that their in-home work environment meets the following requirements:
Home office guidelines - Must have an assigned room to be used as their office where confidentially can be maintained (including discussion where others in their home will not be able to listen in on discussion); or have direct line of sight of their computer screen while working; and where HIPPA confidentially will be maintained. Preferably a dedicated room in the home to be considered a home office.
Work Schedule: Monday through Friday, with every other weekend (Saturday & Sunday) work schedule. Department business hours is 8 am to 8 pm Eastern Standard Time (EST), must be able to work any 8 hour schedule between those hours. These positions work hours will be 10 am to 7pm EST & 12 noon to 8pm EST.
Nurse Appeal Associates are LPN/LVNs, responsible for final review activities pertaining to the investigating and processing of appeals requests from member and providers.
Primary duties may include but not limited to:
Final appeal case file review for completeness and accuracy of information contained within the appeal case file.
Compilation and submission of appeals case files to CMS’ Independent Review Entities (IRE) per CMS regulations;
Interfacing/liaison with those IREs for both Medicare Part C and D, 2nd level appeals across all time zones.
Researching and preparing case files that are reviewed during an Administrative Law Judge Hearing and activities related to preparing for those hearings.
Coordinating the request and effectuation activities for all 2nd and 3rd level and above IRE decisions
Ensures that all related appeal activities are resolved timely to meet regulatory timeframes.
Documents and logs appeal information on relevant tracking systems and mainframe systems.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Performs other duties as assigned.
Current unrestricted LPN or LVN license in the work State required
1 year of related experience; or any combination of education and experience, which would require an equivalent background
2 year of related experience in a managed care setting, utilization review, or equivalent background or experience preferred
At least 1 years of prior Utilization Review or Appeals experience is preferred
Strong oral and written communication skills, organizational, problem solving, and computer skills required
What We Offer
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.