Provider Reimburse Administrator
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.
Ensures accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria.
Primary duties may include, but are not limited to:
- Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of provider education opportunities.
- Translates medical policies into reimbursement rules.
- Analyzes and monitors claims data.
- Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.
- Performs pre-adjudication claims reviews to ensure proper coding was used.
- Prepares correspondence to providers regarding correct doing practices.
- Conducts internal coding reviews as required.
- Prepares and presents reports defining observations and recommendations.
- Interfaces with Corporate Special Investigation Unit on identification and referral of potential fraud.
- Interfaces with local Health Plan representatives regarding provider education initiatives.
- Performs other duties as assigned.
- Requires a BA/BS degree and a minimum of 2 years related experience; or any combination of education and experience, which would provide an equivalent background.
- RN strongly preferred.
Experience with any of the following is strongly preferred:
- Health insurance reimbursement, medical billing, medical coding, auditing or health data analytics.
- Strong written, oral and multitasking skills a plus.
- Proficiency with MS Access and other MS tools preferred.
- CPC certification highly desirable.
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 [email protected] for assistance.
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.