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Anthem, Inc. Nurse Appeals in Roanoke, Virginia


SHIFT: Day Job

SCHEDULE: Full-time

The Nurse Appeals is responsible for investigating and processing appeals requests from contracted providers. Primary duties may include, but are not limited to:

  • Conducts investigations and reviews contracted provider appeals.

  • Reviews medical records of denied services for medical necessity.

  • Extrapolates and summarizes medical information for medical director.

  • Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval, when applicable.

  • Ensures that appeals are resolved timely to meet regulatory timeframes.

  • Documents and logs appeal information on relevant tracking systems and mainframe systems.

  • Generates written correspondence to contracted providers.

  • Utilize leadership skills and serves as a subject matter expert for appeals issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.


Qualifications - Internal

  • 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 applicable state(s) or territory of the United States required.

  • AS/BS in Nursing preferred.

  • For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

  • Requires experience with MS Office products.

  • Prefer experience researching Medicare clinical guidelines: NCD, LCD, Medicare Benefit Policy, etc.

  • Prefer experience reviewing claims and researching CPT codes or ICD-9 codes.

  • UM experience highly desirable

  • Good computer and typing skills.

REQNUMBER: PS41299-Virginia