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Nurse Appeals Lead

Company: Anthem, Inc.
Location: San Diego
Posted on: April 8, 2021

Job Description:

Welcome to the Anthem Careers site! We have been hard at work to improve our job search and application systems to better serve you. It is now easier to find and apply for relevant jobs as well as stay connected with Anthem. Here are a few of the updates you may notice:

  • No more profiles! We no longer require you to create a log in and password to apply for a job and you won't be able to access previously created profiles, but don't worry - we still have your previous application(s) on file and you can still track your status by clicking on the "Track Your Job Application Status" button.
  • Job Alerts - If you had previously registered to receive job alerts and wish to continue to receive these notifications, please re-register by clicking the "job alert" button.
  • NEW! Didn't find a job that is right for you? Join a Talent Network to stay informed on news and job opportunities with the Anthem Team! It is important that you apply using an email address which is unique to you and not shared with a friend, relative, spouse, or significant other. Our recruiting system uses your email address as your unique identifier. If you apply with a shared email address, your application will overwrite any previous applicant record with the same email address. Additionally, please ensure that you use a valid email address, free from typos, as there are a variety of communications which may be sent to the email address with which you apply Your 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 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 care companies and a Fortune Top 50 Company. Location: Must reside in California.-- The Nurse Appeals--Lead is responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers and provide leadership and work direction to other appeals staff. Primary duties may include, but are not limited to:
    • Conducts investigations and reviews of member and provider grievances and appeals.
    • Reviews prospective 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 through inventory management.
    • Investigates and responds to departmental issues and concerns.
    • Provides training for new and existing staff.
    • Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
    • Generates written correspondence to providers, members, and regulatory entities.
    • Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.
    • Supports the Manager when needed
      Qualifications
      • Requires a minimum 5-7 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background.
      • C urrent active unrestricted RN license in California.
      • AS/BS in Nursing preferred.
      • MCG (Milliman Care Guidelines)--and CMCN (Certified Managed Care Nurse) certification strongly preferred.
      • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions. Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem. EEO is the Law Please use the links below to review statements of protection from discrimination under Federal law for job applicants and employees. Anthem, Inc. is committed to helping individuals with disabilities participate in the workforce and ensuring equal opportunity to apply and compete for jobs. If you are an individual with a disability and require a reasonable accommodation to complete the application process, please email Human Resources at ability@icareerhelp.com for further assistance. *WARNING : Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Anthem will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission here by selecting the 'Rip-offs and Imposter Scams' option. Anthem requires a completed online application for consideration of employment for any position.

Keywords: Anthem, Inc., San Diego , Nurse Appeals Lead, Healthcare , San Diego, California

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