Saturday , April 20 2024

Anthem Blue Cross Jobs – Nurse Appeals Sr

Website Anthem

Job Description:

This position may be remote within NC or neighboring states and will be responsible for overseeing a designated region of NC. Home office location: 11000 Weston Parkway, Cary, NC. Candidates must reside in the state of NC or neighboring states (SC, VA, TN).

Job Responsibilities:

  • Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
  • 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.
  • Extrapolates and summarizes medical information for medical director, consultants and other external review.
  • Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
  • Conducts investigations and reviews of member and provider grievances and appeals.
  • Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
  • Generates appropriate written correspondence to providers, members, and regulatory entities.
  • Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.

Job Requirements:

  • 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 NC, SC, VA, or TN required.
  • AS/BS in Nursing preferred.
  • Appeals experience highly desired.
  • 2+ years of UM experience required.
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
  • Proficiency with MS Office products required.
  • Experience researching Medicaid clinical guidelines preferred.
  • Good computer and typing skills required

Job Details:

Company: Anthem

Vacancy Type:  Full Time

Job Location: Newport News, VA, US

Application Deadline: N/A

Apply Here

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