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RN - Nurse Appeals $3,000 Sign On Bonus PS9431

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Medical
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PS9431 Requisition #
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Your Talent. Our Vision. At Anthem, Inc., the Government Business Division is focused on serving Medicaid, Medicare and uninsured individuals. Our commitment and focus on government health programs is the foundation upon which we’re creating better care for our members, greater value for our customers and better health for our communities. Join us and together we will drive the future of health care.
 
Join one of the fastest growing businesses in a company with the largest and most successful Medicaid business in the nation. The associate in this position will be supporting members enrolled in the Minnesota Medicaid Program. 

Nurse Appeals or Nurse Appeals Sr (Job Family) Eagan, MN PS9431
Work Location: Eagan, Minnesota
This is an office based position - Monday-Friday 8 a.m. - 5 p.m.

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 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. 

Nurse Appeals Senior:
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 timeframes. 
• 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. 

* Appeals experience and/or Utilization Management Experience strongly desired.
* Managed Care experience preferred.



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 the scope of licensure  in applicable state(s) or territory of the United States required. 
• AS/BS in Nursing preferred.

Nurse Appeals Senior:
• 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 the scope of licensure  in applicable state(s) or territory of the United States required. 
• AS/BS in Nursing preferred.


Key Qualifications:
• Active, unrestricted RN license in the state of Minnesota.
• Experience applying criteria for medical necessity.
• Critical Care (ER/ICU) experience very helpful.
• Managed Care Experience.
• Minimum of 5 years of direct care experience strongly preferred.

Note: This position may be filled at either the Nurse Appeals or Nurse Appeals Senior Level. The manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.

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.


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