Anthem, Inc. Grievance & Appeals Auditor I in Hialeah, Florida
SHIFT: Day Job
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.
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.
Qualifications - External
Qualifications - External
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.
1 year of experience en Medicare appeals & grievance with a Medicare health plan.
- Ability to provide feedback is a plus.
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 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. 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 firstname.lastname@example.org for assistance.