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Clinical Review Nurse I - NGS - PS30490Location: Syracuse, New York, United StatesNewRequisition #: PS30490Your 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.Preferred Location: Initially Office-Based in Syracuse, NY or South Portland, ME with the possibility to work remotely once training has been completed. Other Anthem locations will be considered.The Clinical Review Nurse l is 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, Home Health and/or Hospice.The clinical review nurse should have the 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.
Current unrestricted RN license required.
1-2 years of clinical experience with adult medicine.
Excellent communication skills.
Demonstrated prioritization, problem solving, and organization skills.
Strong computer skills, including Microsoft Office proficiency.
Prior experience with claim review helpful.
Experience working with adult medicine is preferred.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.
