This job posting isn't available in all website languages

RN Nurse Appeals - Cary, North Carolina (Remote after training) SIGN-ON BONUS! PS22942

PS22942 Requisition #
Your Talent. Our Vision. At Healthy Blue, a strategic alliance of Blue Cross NC and Amerigroup, an Anthem Inc. companyit’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 healthcare.
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.

This position is SIGN-ON BONUS ELIGIBLE!

Location:   This position will work from our Cary, NC office and may be eligible to work remotely after approximately 90 days of training.

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. 

  • Current active unrestricted RN license from North Carolina, or a compact license from a reciprocal state, is required. 
  • AS/BS in Nursing preferred.
  • 2+ years of nursing experience in a Managed Care setting is required.
  • 2+ years of clinical nursing experience is strongly preferred. 
  • Experience in Medicaid/Medicare grievances and appeals and/or Utilization Review is strongly preferred.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, and analytical skills.
  • You must be comfortable using Microsoft Word, Excel and Outlook.

Our process:  If you are identified as a potential candidate, we will send you a Montage on-demand audio pre-screen interview that must be completed and submitted back before you will be moved forward in the process.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2015 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at antheminc.com/careers.

Previous Job Searches

Activity Feed

Job shares through Anthem, Inc.
Darren Powell referred the Compliance Analyst-Virginia Beach, VA or Texas (PS24599) position. 2 days ago
Rosiemariea Thomas referred the Clerk I - Virginia Beach - PS24527 position. Jul 10, 2019
Rosiemariea Thomas referred the Clerk I - Virginia Beach - PS24527 position. Jul 10, 2019
Sandra Fredrickson referred the Agile Product Owner Senior - Salesforce - Any Anthem Location - PS23350 position. Jul 09, 2019

Similar Listings

Durham, North Carolina, United States

📁 Medical

Requisition #: PS19728

Raleigh, North Carolina, United States

📁 Medical

Requisition #: PS24403

Raleigh, North Carolina, United States

📁 Medical

Requisition #: PS23685

Social Media