SHIFT: Day Job
Responsible for post completion examination of grievances and appeals in multiple states.
Primary duties may include, but are not limited to:
Reviews case to determine applicability of, and compliance with, federal and state regulations, enterprise policies and procedures and all related accreditation standards.
Reviews case to assess whether it was appropriately handled as a clinical or administrative request and was correctly processed to avoid prompt pay penalties.
Evaluates urgency of clinical situation to assess appropriate handling, determine if sufficient records were obtained, and review medical records and medical policies to determine if correct criterion has been utilized in each review.
Reviews case documentation to assess appropriate system entries have been made and that the step-by-step process is sufficient to mitigate risk associated with regulatory reviews, accreditation reviews, and potential litigation.
Assists management in process improvement strategies to achieve business objectives.
Prepares audit findings and recommendations for G&A associates and management on a monthly basis. Identifies and communicates error trends to improve overall quality of enterprise G&A team.
Associates at this level handle routine audits and may receive guidance from G&A Auditor IIs.
Requires a BA/BS degree, a minimum of 1 year of grievance and appeals experience; or any combination of education and experience which would provide an equivalent background.
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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.