You must have an active, unrestricted NY state RN license to support the Western NY health plan in Buffalo, NY; Blue Alliance partner of BC/BS of Western NY. You will receive training and the necessary equipment to work from home.
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.
The Nurse Appeals is responsible for investigating and processing medical necessity appeals requests from members and providers, as well as member complaints regarding pharmacies, providers, doctors, clinics and hospitals.
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 and serves as a subject matter expert 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.
Requires a current, active NY RN license, a minimum of 3 years of experience in Quality Management in a managed care or healthcare setting; or any combination of education and experience, which would provide an equivalent background. BSN preferred.
-Experience working with the appeal process required.
-Experience working with the member complaints process required.
-This position requires time management skills, attention to detail, excellent organization skills and the ability to meet deadlines as outlined in our contract with the state.
-Computer literate: MS Office
-Excellent written and verbal communication skills required.
-Must be able to work independently, ask questions and make decisions.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.
*WARNING : Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that an Anthem recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our careers require that you first complete an online application.