Anthem, Inc. Nurse Appeals in Las Vegas, Nevada
SHIFT: Day Job
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.
Responsible for supporting the development and implementation of quality improvement interventions and audits. Responsible for more complex, sensitive and specialized medical necessity and administrative appeals cases such as NICU, transgender, transplants, high level surgeries, cardiac.
Primary duties may include, but are not limited to:
Researches, collects data, and submits and resolves medical necessity and administrative appeals.
Researches and analyzes case and compares to medical guidelines, medical policy and requirements.
Prepares clinical grievances for medical director review. Works with Medical Director on case resolution.
Gathers and validates information for reports, audits and reviews.
Contributes to external reviews site visit preparations by the State, accreditation review and Quality Management Committee; conducts internal monitoring and audits timeline compliance standards.
Ensures case files are accurate to aid in the investigation of cases.
Processes, tracks, trends, and reports complaint and grievances issues.
Prepares complaint and grievance files for Fair Hearings and serves as a subject matter expert on complaints and grievances for non-clinical staff. Participates in quarterly Plan HIPAA audits.
Licensure in the State of New York Required (Multi State Licensure Prefer)
Requires an LVN/LPN; 3 years of related experience in healthcare, insurance, grievance & appeals or managed care; 1 year clinical experience; or any combination of education and experience, which would require an equivalent background. Current unrestricted LPN/LVN license in applicable state(s) required.
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.
We provide a comprehensive benefits package, including generous PTO, medical, dental and vision plans, 401(k) with a match, education assistance, and much more. EOE Dedicated to diversity.
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