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Anthem, Inc. Nurse Appeals Lead in San Jose, California

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 care companies and a Fortune Top 50 Company.

Location: Must reside in California.

The Nurse Appeals Lead is responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers and provide leadership and work direction to other appeals staff.

Primary duties may include, but are not limited to:

  • Conducts investigations and reviews of member and provider grievances and appeals.

  • Reviews prospective 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 through inventory management.

  • Investigates and responds to departmental issues and concerns.

  • Provides training for new and existing staff.

  • Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.

  • Generates written correspondence to providers, members, and regulatory entities.

  • Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.

  • Supports the Manager when needed

Qualifications

  • Requires a minimum 5-7 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 in California.

  • AS/BS in Nursing preferred.

  • MCG (Milliman Care Guidelines) and CMCN (Certified Managed Care Nurse) certification 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 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.

REQNUMBER: PS44530-California

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