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Description SHIFT: Day JobSCHEDULE: Full-timeYour 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. Location: Work from home office. Must work business hours in Eastern or Central Time Zone.The Clinical Review Nurse is responsible for reviewing documentation and making clinical determinations for payment supporting claims submitted to Medicare. Primary duties may include, but are not limited to:
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.
Adapts to a wide variety of medical review topics and multiple Medicare lines of business to include Part A, Part B, and DME.
Articulates clearly with other clinicians to include medical doctors, nurses, and support personnel is required via teleconference education sessions.
Qualifications Requires:
Current unrestricted RN license required.
Two (2) years’ clinical experience.
Knowledge of Medicare a plus.
Ability to comprehend medical policy and criteria to clearly articulate health information required.
Preferred experience in Hospice and Home Health/ Fraud detection.
Excellent communication skills.
Demonstrated prioritization, problem solving, and organization skills.
Strong computer skills, including Microsoft Office proficiency.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 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.REQNUMBER: PS38177
