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Grievance/Appeals Analyst I - Wallingford, CT or Mason, OH - PS26637Location: Mason, Ohio, United StatesNewRequisition #: PS26637Your 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/Appeals Analyst ILocation: This is an in-office only position and may be filled at either of the below offices
4241 Irwin Simpson Road, Mason, OH 45040
108 Leigus Road, Wallingford, CT 06492
Work Hours: Monday through Friday (standard business hours) with 1-2 mandatory Saturday’s per monthThis is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes 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 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 and appeal issues and completion of the respective written communication documents to convey the determination.
Prepare appeal packets to be provided to an external review entity, process decisions and update internal systems accordingly.
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.
Qualifications:
Requires a High school diploma or GED;
3 to 5 years’ experience working in grievances and appeals, claims, or customer service preferred;
Familiarity with medical coding and medical terminology preferred
Demonstrated business writing proficiency preferred
An understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology preferred;
Or, any combination of education and/or experience which would provide an equivalent background.
Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Experience with GBD Facets, PEGA, MS Word and Outlook preferred.
Experience with Medicare Appeals and IRE process strongly 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.
