Nurse Appeals Sr-18816

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.

Responsible to investigate and process most complex grievances and appeals requests from members and providers. Essential duties may include, but are not limited to: Conducts investigations and reviews of member and provider grievances and appeals. Reviews prospective, concurrent or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes essential 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 appropriate written correspondence to providers, members, and regulatory entities. 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. Performs other related duties as required.

Associate's Degree in Nursing and 4-5 years experience in a managed care healthcare setting, or equivalent combination of education and experience required. Current unrestricted RN license in applicable states required. BSN preferred. Requires strong oral and written communication skills, organizational and problem-solving skills, PC skills, and research and analytical skills.