Your Talent. Our Vision. At Anthem, Inc., it's a powerful combination, and the foundation upon which we're creating greater 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.
Appeals Nurse - Atlanta, GA 120736
Work Location - Atlanta, GA Amerigroup Office during training; w@home after successful completion of training.
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.
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 Georgia required.
• Experience with medical record audit.
• Strong critical thinking, analytical and research skills.
• Ability to adapt to change and work in a high volume environment.
• Knowledge of InterQual guidelines.
• Proficiency with MS Word, Excel and Outlook and Adobe.
• Experience with Facets and Macess preferred.
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers.
Title: RN Nurse Appeals Medicaid - Atlanta, GA 120736
Requisition ID: 120736
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