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.
- Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
- Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
- Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
- Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
- Extrapolates and summarizes medical information for medical director, consultants and other external review.
- Serves as technical resource to team and may be assigned to work on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives.
- Conducts investigations and reviews of member and provider grievances and appeals.
- Generates appropriate written correspondence to providers, members, and regulatory entities.
- 4 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 within the scope of licensure in applicable state(s) or territory of the
- United States required.
- AS/BS in Nursing preferred.
- For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Vacancy Type: Full Time
Job Location: Lynchburg, VA, US
Application Deadline: N/A