Anthem, Inc. Nurse Appeals in Roanoke, Virginia
SHIFT: Day Job
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.
- Anthem, Inc. Jobs