Anthem, Inc. Clinical Review Nurse I in Harrisburg, Pennsylvania
SHIFT: Day Job
Your Talent. Our Vision. At National Government Services (NGS), an independent subsidiary of Anthem, Inc. and one of the largest Medicare contractors in the country, it’s a powerful combination. It’s 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.
The Clinical Review Nurses are responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. This position applies clinical knowledge to assess and ensure services/items billed are reasonable and necessary, supported by national and local policies, are under accepted billing and coding practices, and meet standards of medical care.
This position is also responsible for adapting to a wide variety of medical review topics in Part A appeals. Ability to articulate clearly with other clinicians to include medical doctors, nurses, and support personnel is required. Responsible for reviewing and making medical determinations as to whether a claim meets the benefits the member carries.
Primary duties may include, but are not limited to:
Conducts investigations and reviews of member and provider grievances and appeals.
Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials.
Generates appropriate written correspondence to providers, members, and regulatory entities.
Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. If you are not vaccinated, your offer will be rescinded unless you provide –and Anthem approves –a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.
Requires AS in nursing and minimum of 1 year of clinical experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license required.
BS in nursing preferred.
Ability to comprehend medical policy and criteria to clearly articulate health information strongly preferred.
Two (2) years’ clinical experience.
Excellent communication skills, demonstrates prioritization, problem solving, and organization skills. Strong computer skills, including Microsoft Office proficiency.
Skilled nursing facility, inpatient, home health and hospice experience helpful.
Experience with MAS or other CMS mainframe system helpful.
Prior experience with claim review helpful.
Work from home position.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.