Grievance/Appeals Representative II
DescriptionSHIFT: 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 care companies and a Fortune Top 50 Company.
Responsible for reviewing, analyzing and processing policies related to claims events to determine the extent of the company's liability and entitlement. Primary duties may include, but are not limited to:
- Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
- Contacts customers to gather information and communicate disposition of case; documents interactions.
- Generates written correspondence to customers such as members, providers and regulatory agencies.
- Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
- May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
- Prepares files for internal or external review by analysts, medical staff or outside consultant.
- Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
- Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to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.
- High school diploma or GED equivalent
- Minimum of 2 years experience in customer service; or any combination of education and experience which would provide an equivalent background.
- 2 years experience in customer service in a managed care environment, medical office, or health insurance preferred.
- Ability to organize work, set and manage multiple priorities in a time sensitive manner is strongly preferred.
- Good oral and written communication skills, basic word processing, data base management, spreadsheet skills, PC proficiency and claims knowledge strongly preferred.
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.
Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.