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Grievance/Appeals Analyst II

Location: Coconut Grove, FL
Job Family: Claims
Req #: PS36924
Date Posted: Jun 30, 2020


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At HealthSun, a proud member of the Anthem, Inc. family of companies, 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.

HealthSun Grievance/Appeals Analyst II

This role is 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. 


  • Requires a HS diploma or equivalent
  • 1-3 years of Grievance & Appeals analyst experience and 3-5 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.
  • Bilingual in Spanish preferred.
  • For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.

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