Nurse Appeals Sr/ Nurse Appeals - Central Region - PS30752

Anthem, Inc in San Francisco, CA

  • Industry: Healthcare - Nursing - Others
  • Type: Full Time
position filled
Nurse Appeals Sr/ Nurse Appeals - Central Region - PS30752**Location:** **Georgia, United States****Requisition #:** PS30752**Post Date:** Jan 09, 2020Location: This position willallow you to work from your home office. Residents of Georgia preferred though we will consider candidates throughout the Central region.This **Nurse Appeals** role will primarilysupport **Medicaid Health Plans within the Central Region** . This role isresponsible for investigating and processing work related to member potentialquality of care events, clinical grievances and incidents reports.This position be filled as a Nurse Appeals Sr. or Nurse Appeals.Primary duties may include,but are not limited to:· Conductsinvestigations and reviews of all pertinent information related to member potentialquality of care events, clinical grievances and incident reports.· Extrapolatesand summarizes medical information for medical director, consultants and other internalor external review entities.· Preparesrecommendations to either uphold or deny appeal and forwards to MedicalDirector for approval.· Ensureswork is resolved timely to meet regulatory and contract timeframes.· Documentsand logs information on relevant tracking systems and mainframe systems.· Generateswritten correspondence and/or verbal discussion with providers, members, andregulatory entities.Utilize leadership skillsand serves as a subject matter expert for potential quality of care issues andis a resource for clinical and non-clinical team members in expediting theresolution of outstanding issues.An Equal Opportunity Employer/Disability/VeteranRequires:· 2+ years’ experience in work related to potential quality of care investigations· Managedcare experience, preferably in Medicaid· 3+ years of RN experience strongly preferred· Currentactive unrestricted RN license to practice as a Registered Nurse in a COMPACT Licensurestate or a Georgia license is required. If you reside in Tennessee, you will need a Tennessee license.· Previousexperience in Quality Management handling sensitive matters preferred.· AS/BSin Nursing preferred.· Requiresstrong oral, written and interpersonal communication skills, problem-solvingskills, analytical and critical thinking skills, and facilitation andpresentation skills.· Experienceworking in Microsoft Office and Electronic Medical Record systems

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