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Description SHIFT: Day JobSCHEDULE: Full-timeYour 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.Grievance/Appeals Analyst I 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. Grievance/Appeals Analyst IIThe Grievance/Appeals Analyst II is responsible for reviewing, analyzing and processing non-complex and some complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department 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: 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, and completion of the respective written communication documents to convey the determination. The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments. Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. Identify opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed. Grievance/Appeals Analyst Sr.The Grievance/Appeals Analyst Sr. is responsible for reviewing, analyzing, and processing complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department and the completion of written communication documents to convey the determination. Primary duties may include, but are not limited to: Represents the highest level of expertise that is required to respond to regulators, media inquiries, member and provider issues escalated to the Executive Leadership Team (ELT) and regulatory agencies. Researches and makes determinations on complex appeals or grievances that come from a variety of sources including the state/federal regulators, members, media, attorneys representing members and inquiries received from any of these sources. This includes reviewing and extrapolating member Evidence of Coverage language for interpretation where ambiguity may exists and initiates a recommendation to Contracts and/or Legal. Works with the Legal Department on various types of cases such as pleadings received from the various regulators, actions and violations and with Public Relations and Government Relations on research and resolution of media issues. Qualifications Experience will determine the job levelGrievance/Appeals Analyst IRequires a High school diploma or GED; 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, and analytical skills.Grievance/Appeals Analyst IIRequires a HS diploma or equivalent; 1-3 years of Grievance & Appeals analyst experience and 3-5 years’ experience working in grievances and appeals, claims, or customer service; or any combination of education and experience, which would provide an equivalent background. Associates degree preferred.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Grievance/Appeals Analyst Sr.Requires a HS diploma or equivalent; 3-5 years of Grievance & Appeals Analyst experience and 3-5 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience, which would provide an equivalent background. Associates degree preferred.For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Preferred skills:Excellent writing skillsExperience with NextGen a plusAnthem, 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. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.REQNUMBER: PS42423-US
