Appeals Nurse RN (Insurance Industry Experience) Iselin, NJ 123569
Anthem, Inc. is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.
Amerigroup, a proud member of the Anthem, Inc. family of companies, is focused on serving Medicaid, Medicare and uninsured individuals and families. We improve access to quality health care for the financially vulnerable, seniors and people with disabilities.
Here, you can do work that matters and offers opportunities for personal and professional growth. Together, our associates are transforming health care with trusted and caring solutions.
RN Nurse Appeals - Iselin, NJ 123569
Responsible for investigating and processing medical necessity appeals requests from members and providers.
Primary duties may include, but are not limited to:
o Conducts investigations and reviews of member and provider medical necessity appeals.
o Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
o Extrapolates and summarizes medical information for medical director, consultants and other external review.
o Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
o Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
o Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
o Generates written correspondence to providers, members, and regulatory entities.
o 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.