Nurse Appeals - 39829SY - (US-CA-Woodland Hills - 91399)

Minimum Education: Tech School
Job Type: Full Time
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WellPoint
is the nation's leading health benefits insurer and a Fortune Top 50 company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to be the most trusted choice for consumers and a leader in affordable quality care with an unyielding commitment to meeting the needs of our diverse customers.

Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

Responsible to investigate and process grievances and appeals requests from members and providers. Primary 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.

Skills:
Requires Associate's Degree in Nursing and 2-3 years experience in a managed care healthcare setting, or any combination of education and experience, which would provide an equivalent background. Requires current unrestricted RN license in applicable state(s). BSN preferred. WellPoint is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2008 DiversityInc magazine Top 50 Company for Diversity

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