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RN Nurse - Medicaid Appeals - (MCO exper a plus!) Louisville, KY office initally (PS6560) in Louisville, KY at Anthem, Inc.

Date Posted: 7/11/2018

Job Snapshot

Job Description

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 benefits companies and a Fortune Top 50 Company.
Location: This position will require you to work from our Louisville, KY office initially. There may be some flexibility to work from home at some point in the future
The Nurse Appeals is responsible for supporting the development and implementation of quality improvement interventions and audits; investigates and processes 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.
  • Participates in quarterly Plan HIPAA audits.
  • 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 in the State of Kentucky required.
  • AS/BS in Nursing preferred.
  • Experience with Medicaid in Managed Care or Health Insurance industry preferred.
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 EOE. M/F/Disability/Veteran.


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