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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.Duties & Responsibilities Behavioral Health Appeals Coordinator I/Sr. – Job Family Location: Remote Based Hours of Operation: 8:30 a.m. – 5 p.m. PSTBehavioral Health Appeals Coordinator Sr. Responsible for investigating and processing the most complex grievances and appeals requests from members and providers related to behavioral health services. Serves as a technical resource to team and may be assigned to work on projects in support of medical policy and/or managed care initiatives. Primary duties may include, but are not limited to: Investigates and reviews member and provider grievances and appeals. Generally works on issues that are of a complex nature. Serves as an internal resource for lower level behavioral health appeal coordinators and staff. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review. Prepares recommendations to either uphold or deny appeal and forwards to medical director for approval. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs information on tracking systems and mainframe systems. Generates appropriate written correspondence to providers, members, and regulatory entities. Participates in projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives. Behavioral Health Appeals Coordinator Responsible for investigating and processing grievances and appeals requests from members and providers related to behavioral health services. Primary duties may include, but are not limited to: Investigates and reviews member and provider grievances and appeals. Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity. Extrapolates and summarizes medical information for medical director, consultants and other external review and forwards to Medical Director for determinations. Ensures that appeals and grievances are resolved timely to meet regulatory timeframes. Documents and logs information on tracking systems and mainframe systems. Generates appropriate written correspondence to providers, members, and regulatory entities. Qualifications Requirements Behavioral Health Appeals Coordinator Sr. Requires MS in social work, RN or degree in a related behavioral health field and minimum of 4 years of experience in a managed care/healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor or RN license to practice as a health care professional within scope of licensure in applicable state(s) or territory of the United States required. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.Behavioral Health Appeals Coordinator Requires MS in social work, RN or degree in a related behavioral health field and minimum of 2 years of experience in a managed care/healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor, or RN license to practice as a health care professional within scope of licensure in applicable state(s) or territory of the United States required. For URAC accredited areas the following applies: Requires 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 ability@icareerhelp.com for assistance.REQNUMBER: PS65369-US
