Job details
Job type full-time
Full job description
Description
Shift: day job
Schedule: full-time
Your talentOur visionAt 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 communitiesJoin 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.
Location: miami, fl
Hours: m-f 8am-5pm; overtime may be required
Due to the current covid-19 (coronavirus) pandemic, this position will require you to work remotely from your home with the flexibility to return to a regular, in-office work environmentAs we continue to monitor guidance from cdc and state officials there may be times you would need to report to the office on a monthly or quarterly basis for team meetings or engagement activities.
The g&a analyst i, ii or srIs responsible for reviewing, analyzing and processing pre service and post service grievances and appeals requests in the enterprise grievance & appeals department from customer types (i.eMember, provider, regulatory, and third party) and multiple products (i.eHmo, 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 requirementsAs 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 determinationThe 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 departmentsObtaining 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.
Qualifications
Requires a hs diploma or equivalent and a minimum of 1 year of grievance & appeals analyst experience (minimum 3 years for sr.) and 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 backgroundAssociates degree preferred.
For urac accredited areas the following applies: prefer strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Bilingual spanish highly preferred
Anthem, incIs ranked as one of america’s most admired companies among health insurers by fortune magazine and has been named a 2020 best employers for diversity by forbesTo learn more about our company and apply, please visit us at careers.antheminc.comAn equal opportunity employer/disability/veteranAnthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all anthem positions.
