Anthem Grievance/Appeals Analyst I/II/Sr. - Gilbert, MN, Eagan, MN, Colorado Springs, CO, Newbury Park, CA - (PS10331) in Jefferson City, Missouri

Grievance/Appeals Analyst I/II/Sr. - Gilbert, MN, Eagan, MN, Colorado Springs, CO, Newbury Park, CA - (PS10331)

Location: United States

Field: Claims

Requisition #: PS10331

Post Date: Aug 10, 2018

Grievance/Appeals Analyst I/II/Sr

Manager will determine level based upon the selected applicant’s skillset relative to the qualifications listed for this position.**Hiring Manager will be determined at a later time.

Level I

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

Level 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.

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.

  • 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.

  • WGS experience preferred

  • STAR experience preferred

  • Previous claims procedure or adjustment experience preferred.

  • This position must work out of the office at: 700 Broadway, Denver, CO or 3634 Maryland Parkway, Las Vegas, NV - Work from home is not an option.

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.