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RN Nurse Appeals - Cary, North Carolina (in-office) SIGN-ON BONUS! PS22942

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Medical
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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 is 100% office-based in the Raleigh-Durham area, at our new office location in Cary.


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.
AnEqualOpportunityEmployer/Disability/Veteran





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Anthem, Inc.'s supplier registration process will automatically enter your information into our prospective supplier database.

Anthem does not do business with persons or entities identified on the General Services Administration's List of Parties Excluded from Federal Programs and the HHS\OIG List of Excluded Individuals\Entities.

Anthem, Inc. Purchase Order Terms

Anthem's standard payment terms are net 50. Payment terms will be calculated from the invoice date, which should also reflect the date goods or services were received.

Anthem also offers various discount options that provide you with the opportunity for early payment and we are also encouraging our suppliers to participate in our electronic funds transfer (EFT) method of payment. The EFT method of payment will improve the efficiency of our payment processes and ensure that you are paid properly and on time.

Anthem, Inc. Supplier Registration Process

*Please Note: To complete the supplier registration process, you will leave antheminc.com and will be directed to the Ariba Network (AN) site. Once there please click on Register as New Supplier to complete the online registration form and follow the on-screen instructions.

Supplier Registration

Anthem, Inc. utilizes the Ariba Network to determine qualified suppliers that meet Anthem’s business need. Prospective suppliers should complete Ariba’s Supplier Registration Process.*

*Please Note: To complete the supplier registration process, you will leave antheminc.com and enter the Ariba Network (AN) site. Once there, please click on 'Register as New Supplier' on the left-hand side of the screen, complete the online registration form and follow the on-screen instructions.

Anthem does not do business with persons or entities identified on the General Services Administration's List of Parties Excluded from Federal Programs and the HHS\OIG List of Excluded Individuals\Entities.

What to expect next after registration

Anthem Inc.'s Procurement department will review your registration and additional materials. If our sourcing needs align with your goods or services, an Anthem Buyer will contact you to discuss next steps and other pertinent details. If there is no current need, your information will remain in our prospective supplier database for one year for processing against future requests.

Supporting Documents

Guidelines for Prospective Suppliers (PDF)

Company Policy and Procedures (PDF)

To obtain a copy of Anthem's Supplier Travel Guidelines, please send an email to TravelPoint@anthem.com.