Anthem Nurse Appeals - Remote - Mason, Ohio - (PS15327) in Youngstown, Ohio

Nurse Appeals - Remote - Mason, Ohio - (PS15327)

Location: Ohio, United States

Field: Medical

Requisition #: PS15327

Post Date: Dec 04, 2018

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.

Nurse Appeals - Medicare Complaints, Appeals & Grievance

*Thework schedule for this position is** Tuesday thru Saturday with Sundayrotation - business hours are 8 am to 8 pm EST, and the selected candidatemust be able to work an 8 hour shift between those hours, including holidays ona rotational basis.

* **Training is required for the selected candidate - Mon thru Friday work scheduleduring training (approx. 3 – 6 months), once independent with expedited casereviews will transition to Tuesday thru Saturday work schedule.

Ifthe selected candidate is internal (Anthem associate) and is currently W@H,they are permitted to remain as a W@H associate, but must be willing to go toan office location as necessary. Training is virtual for internalassociates.

Ifthe selected candidate is external (not current Anthem associate), they must workfrom the on-site Mason, Ohio office location for at least 3 – 6 months duringtraining or they are independent with expedited case reviews. To transition towork@home, must have a dedicated room or location in home to be set-up as aprivate, secure in-home office location to allow for compliance with HIPAAregulations.

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 andprovider medical necessity appeals.

  • Reviews prospective, inpatient, or retrospectivemedical records of denied services for medical necessity.

  • Extrapolates and summarizes medical informationfor medical director, consultants and other external review.

  • Preparesrecommendations to either uphold (deny) or overturn (approve) requestedappealed service and forwards to Medical Director for final review anddecision.

  • Ensures that appeals and grievances are resolvedtimely to meet regulatory time frames.

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

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

  • Utilize leadership skills and serves as a subjectmatter expert for appeals/grievances/issuesand is a resource for clinical and non-clinical team members in expeditingthe resolution of outstanding issues.

  • Requires2 years of experience in a managed care healthcare setting - prefer 2years’ experience in reviewing medical records, investigation, and/orprocessing appeals within a managed care setting; or any combinationof education and experience, which would provide an equivalent background.

  • Currentactive unrestricted RN license to practice nursing within the scope oflicensure in applicable state(s) or territory of the United Statesrequired.

  • AS/BSin Nursing preferred

  • Requires strongoral, written and interpersonal communication skills, problem-solvingskills, facilitation skills, and analytical skills.

  • Preferexperience researching Medicare clinical guidelines: NCD, LCD, MedicareBenefit Policy.

  • Preferexperience with Facets, Macess, Medisys, WMDS, ECC, and/or FileNet

  • Preferexperience reviewing claims and researching CPT codes or ICD-9 codes

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 An Equal Opportunity Employer/Disability/Veteran.