Experience:
1-3 years of experience
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Employment Type:
Full time
Posted:
7/20/2019
Job Category:
Analysis
Grievance/Appeals Analyst I/II - Cocont Grove, FL -...
(This job is no longer available)
Anthem, Inc. | Miami, FL
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Job Description

Your Talent. Our Vision. At HealthSun, 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 I/II

* Manager will determine level based upon the selected applicant's skillset relative to the qualifications listed for this position.*

Grievance/Appeals Analyst I

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 grievances 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.
* Analyzes and renders determinations on assigned 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 II

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. Must perform all the job duties of the Grievance/Appeals Analyst I.

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.

Qualifications

Grievance/Appeals Analyst I

* Requires a High School 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.
* Proficient using Microsoft Excel, Outlook, Power Point and Word.
* Working knowledge with Medicare Advantage plan, Medicare CMS Guidance and Regulations preferred.
* Medicare experience preferred.
* Bilingual English and Spanish (reading and writing) is strongly preferred.

Grievance/Appeals Analyst II

* Requires 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.
* Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
* Proficient using Microsoft Excel, Outlook, Power Point and Word.
* Working knowledge with Medicare Advantage plan, Medicare CMS Guidance and Regulations preferred.
* Medicare experience preferred.
* Bilingual English and Spanish (reading and writing) is 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.

About Anthem, Inc.

The Anthem National Accounts business unit serves members of Anthem Blue Cross and Blue Shield in the 11 states of Colorado, Connecticut, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.) and Wisconsin, in addition to members of Blue Cross of California, Blue Cross Blue Shield of Georgia, and Empire Blue Cross Blue Shield in portions of the state of New York. All are independent licensees of the Blue Cross Blue Shield Association. ®Registered marks of the Blue Cross and Blue Shield Association. Anthem is a registered service mark.