Anthem, Inc. Grievance/Appeals Analyst I in Coconut Grove, Florida
SHIFT: Day Job
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 care companies and a Fortune Top 50 Company.
$500 Sign On Bonus
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, 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
Analyzes and renders 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 which 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
Requires a HS diploma or GED equivalent
A minimum of 3 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background
Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly preferred
Medicare/Medicaid experience preferred
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
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. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. 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. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact firstname.lastname@example.org for assistance.