Nurse Appeals -Miami PS1051
at Anthem, Inc.
Posted in Management 13 days ago.
This job brought to you by eQuest
Location: Miami, Florida
Anthem, Inc. is the nation's leading health benefits company serving the needs of approximately 40 million medical members nationwide.
Your Talent. Our Vision. At Simply Healthcare, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. We are a Florida licensed health maintenance organization that serves individuals enrolled in Medicaid and/or Medicare programs, 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.
RN Nurse Appeals
Responsible for investigating and processing and medical necessity appeals requests from members and providers.
- Primary duties may include, but are not limited to:
- Conducts investigations and reviews of member and provider medical necessity appeals.
- Reviews prospective, inpatient, 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.
- Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems. Generates written correspondence to providers, members, and regulatory entities.
- Utilize leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non-clinical team members in expediting the resolution of outstanding issues.
- Requires an active, unrestricted RN License for the state of Florida
- Requires 2 years of experience in a managed care healthcare setting
- Experience in Medicare/Medicaid grievances and appeals preferred
AS/BS in Nursing preferred.
- 2 years clinical experience
- Proficient in Excel, Word, and Outlook
This position must sit in our Miami, Florida office
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran
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