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Grievance/Appeals Auditor I

Location: OH
JobFamily: Quality
Req #: PS73015
Date Posted: May 13, 2022

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Description:

Description

SHIFT: Day Job

SCHEDULE: Full-time

Be part of an extraordinary team

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

The Grievance/Appeals Auditor I is responsible for post completion examination of grievances and appeals in multiple states.

How you will make an impact:

  • 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 II's.

Qualifications

Minimum Requirements:

  • 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.

Preferred Skills, Capabilities, and Experiences:

  • Microsoft Word & Excel 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.

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 Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. 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 age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. 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.