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Nurse Appeals Associate - Tamp...

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Job Summary

Company
Anthem
Location
Tampa, FL
Industries
Other/Not Classified
Job Type
Full Time
Employee
Career Level
Experienced (Non-Manager)
Job Reference Code
4298_PS3702

Nurse Appeals Associate - Tampa, FL - PS3702

About the Job

Description
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.

Nurse Appeal Associate - Tampa, FL - PS3702

This position is responsible for supporting the development and implementation of quality improvement interventions and audits.

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.
Qualifications
  • Requires an LVN/LPN.
  • 1 year of related experience; or any combination of education and experience, which would require an equivalent background.
  • Current unrestricted LPN/LVN license in the state of Florida required.
  • Strong computer skills preferred.
  • At least 1 year of experience in a managed care setting conducting medical necessity reviews 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 antheminc.com/careers. EOE. M/F/Disability/Veteran.
 

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