Description SHIFT: Day Job SCHEDULE: Full-time Grievance/Appeals I,II, Senior Ohio Be part of an extraordinary team.
We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change.
Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
Build the Possibilities.
Make an extraordinary impact.
$500 SIGN ON BONUS This 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.
Grievance/Appeals Analyst I 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 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.
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 Senior 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 Requirements Grievance/Appeals Analyst I HS diploma or GED 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 background.
Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company’s internal business processes, and internal local technology is strongly preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Grievance/Appeals Analyst II HS diploma or equivalent Minimum of 1 year of Grievance & Appeals analyst experience 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 background.
Associates degree preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Grievance/Appeals Senior: HS diploma or equivalent and a minimum of 3 years of Grievance & Appeals Analyst experience 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 background.
Preferred: Associates degree preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have 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 Worlds Most Admired Companies among health insurers by Fortune magazine, and a 2020 Americas 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 abilityicareerhelp.com for assistance.
REQNUMBER: PS71593-US