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

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PS15327 Requisition #
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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
 

***The work schedule for this position is Tuesday thru Saturday with Sunday rotation - business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8 hour shift between those hours, including holidays on a rotational basis. 

 

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


If the 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 to an office location as necessary.  Training is virtual for internal associates.

 

If the selected candidate is external (not current Anthem associate), they must work from the on-site Mason, Ohio office location for at least 3 – 6 months during training or they are independent with expedited case reviews. To transition to work@home, must have a dedicated room or location in home to be set-up as a private, secure in-home office location to allow for compliance with HIPAA regulations. 


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 (deny) or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.
  • Ensures that appeals and grievances are resolved timely to meet regulatory time frames.
  • 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/issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues. 

  • Requires 2 years of experience in a managed care healthcare setting - prefer 2 years’ experience in reviewing medical records, investigation, and/or  processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background.
  • Current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States required.
  • AS/BS in Nursing preferred
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Prefer experience researching Medicare clinical guidelines: NCD, LCD, Medicare Benefit Policy.
  • Prefer experience with Facets, Macess, Medisys, WMDS, ECC, and/or FileNet
  • Prefer experience 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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.


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Your education. Our inspiration.

This is a brilliant combination. This is where people united with passion and a purpose can make a huge impact. This is Anthem, where innovation is the force that will drive the future of health care.

So what drives you? If it’s the desire to build a career where the work you affects millions, you’re in the right place. Take what you’ve learned to the next level, combine your knowledge with our experience, expertise and resources; and start changing peoples’ lives.

Anthem is one of Fortune magazine’s Most Admired Companies, has a wealth of opportunities for students and graduates who are ready to make a difference.

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Student Programs

Ready to build a career where you make a difference and impact millions of lives? Review our undergraduate and graduate internship programs where you can combine your knowledge, experience and expertise in a growing industry.

Build your career, or even start it through our undergraduate and graduate internships that help us identify future leaders. We’re transforming our industry and here’s the chance to be a part of it.

 

MBA Program

What drives you? For MBA candidates our leadership development program is an opportunity to apply your academic and professional experience in pursuit of a rewarding and challenging career with one of Fortune magazine’s most admired companies.

Anthem is transforming healthcare for millions as one of the nation’s leading health benefit companies. We are working to not just navigate the changes in the health care market but lead. By leading we can build on our commitment to make a lasting, positive difference for our consumers, care providers, and communities.

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Your Questions, Answered

You have to be at least 18 years of age (unless part of an approved/sponsored program) and currently enrolled in an accredited US college or university. For actuarial students, sitting for or having at least one exam completed by the time your interview is an advantage.

Visit our main page and search internships – apply via APPLY link on the specific opportunity.

We offer internships that are 3 months, 6 months and part-time during the school year. Our opportunities are based on business needs and student availability.

We are delighted to get to know you! Our team participates in various on-campus events throughout the year and from time to time hosts meetings in our offices. The fastest way to see where you stand in the application process is to log into our system to check your status.

Because internships are temporary positions, the only benefits offered at this time are access to our onsite fitness facilities, and the ability to contribute to a 401k. We do, however, offer opportunities to get connected, and be mentored through our various ARGs (Associate Resource Groups).