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Registered Nurse

Company: Anthem, Inc
Location: Lexington
Posted on: September 16, 2020

Job Description:

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At Anthem, Inc. it'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.NurseAppeals,is responsible for investigating and processing medical necessity requested appealreceived from members and providers. Primary duties may include, but are notlimited to: + Conducts investigations and reviews of member andprovider medical necessity appeals. + Reviews prospective, inpatient, or retrospectivemedical records of denied services for medical necessity. + Extrapolates and summarizes medical information formedical director, consultants and other external review entities. + Prepares recommendations to either uphold (deny) oroverturn (approve) requested appealed service and forwards to MedicalDirector for final review and decision. + Ensures that appeals are resolved timely to meetregulatory timeframes. + Documents and logs appeal information on relevanttracking systems and mainframe systems. + Generates written correspondence to providers, members,and regulatory entities.+ Utilize leadership skills and serves as a subjectmatter expert for appeals of care issues and is a resource for clinicaland non-clinical team members in expediting the resolution of outstandingissues.Qualifications Qualifications:+ Requires 3 - 5 years of clinical experience as aRegistered Nurse.+ Current active unrestricted RN license to practicenursing within the scope of licensure in applicable state(s) or territoryof the United States required. + AS/BS in Nursing preferred+ Preferred 2 years in a managed care healthcare setting- reviewing medical records, investigation, and/or processing appealswithin a managed care setting; or any combination of education andexperience, which would provide an equivalent background. + Prefer experience researching Medicare clinicalguidelines: NCD, LCD; Medicare Benefit Policy. + Prefer experience reviewing claims and researching CPTcodes or ICD-9 codes + External selected candidates must live at least an houror less from the office or willing to relocate or work from the Mason Ohiooffice for a minimum of 6 months.Thework schedule for this position is Tuesday through Saturday with Sundayrotation (2nd shift), business hours are 8 am to 8 pm EST, and the selectedcandidate must be able to work an 8 hour shift between those hours, includingholidays on a rotational basis. Trainingis Monday thru Friday, for approximately 3 - 4 months, once independent withexpedited case reviews will transition to 2nd shift work schedule whichincludes Saturday as a regular work day, with Sunday rotation.REQNUMBER: PS37967

Keywords: Anthem, Inc, Lexington , Registered Nurse, Healthcare , Lexington, Kentucky

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