Anthem Grievance/Appeals Analyst I/II - Richmond, VA - 134399 in Richmond, Virginia

/ Your 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 I/II

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.

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.

Requirements:

Level I:

  • High school diploma or GED

  • Minimum of 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.

  • TriMED experience required.

  • Or any combination of education and/or experience which would provide an equivalent background.

Level II:

  • Meets Level I qualifications.

  • Minimum of 1 to 3 years of Grievance/Appeals Analyst experience and 3 to 5 years' experience working in grievance and appeals, claims or customer service.

  • Or any combination of education and experience which would provide an equivalent background.

  • Associates degree preferred.

/ Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran. /

Job Claims

Equal Employment Opportunity Statement Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.

Title: Grievance/Appeals Analyst I/II - Richmond, VA - 134399

Location: VA-Richmond

Requisition ID: 134399