Anthem, Inc. Grievance/Appeals Analyst I in Miami, Florida
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Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and 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 at one of America's leading health benefits companies and a Fortune Top 50 Company.
Grievance and Appeals Analyst I
Open to a remote arrangement but must be within a commutable distance (50 miles) of an Anthem office location. Target locations include: OH, IN, FL, TX, GA, CO, TN.
This position focuses on the processing of Medicare appeals (reviews of adverse claims and pre-authorization decisions). This is an entry-level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre-service and post-service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, SNP, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. Primary duties may include, but are not limited to:
Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. The file review components of the URAC and NCQA accreditations are "must pass" items to achieve the accreditation. They will analyze and render determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities that require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
This position offers flexible work-hours to include a Saturday workday with Monday or Wednesday day off.
Requires a High school diploma or GED equivalent from an accredited institution.
3 to 5 years experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background.
For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, organization/time management skills, and analytical skills.
Additional qualifications include:
Claims processing knowledge is preferred
Medicare Advantage Plan knowledge is required
Medicare/Medicaid dual plan coordination is preferred
Macess and Facets systems experience is preferred
MS Office - Excel, Word, and Outlook proficiency is preferred
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.
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