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Anthem, Inc. SCA Appeals Representative I in Jefferson City, Missouri

Description

SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At National Government Services (NGS), an independent subsidiary of Anthem, Inc. and one of the largest Medicare contractors in the country, it’s a powerful combination. It’s 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.

The SCA Appeals Representative I position in the NGS Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part B) 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:

  • Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.

  • 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. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.

  • Responsibilities exclude conducting any utilization or medical management review activities which will require the interpretation of clinical information.

  • The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Qualifications

Training hours: 2 month training class Monday through Friday 7:30am- 4:00pm hours may vary

Attendance during training is considered mandatory with time off highly discouraged

Work hours: Monday through Friday starting between 6:00am – 10:00am working an 8 hour shift

Hourly rates are non- negotiable

Broward County, FL

15.02

Bryan County, OK

14.30

Cincinnati, OH

14.49

Cooke County, TX

13.56

Denison, TX

14.47

Harrisburg, PA

15.01

Hingham, MA

16.46

Indianapolis, IN

14.45

Kanawha County, WV

13.32

Lamar County, TX

13.80

Louisville, KY

13.92

Manchester, NH

15.63

Mason County, OH

13.97

Milwaukee, WI

15.40

Philadelphia, PA

14.68

Pinal County, AZ

13.78

Richmond, VA

13.85

South Portland, ME

15.26

Syracuse, NY

13.87

Requires a High school diploma or GED; up to 2 years’ experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, all of the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background.

Preferred skills

  • Medical records experience

  • Strong written communications- must be able to compose professional correspondence

  • Billing/claims experience

  • Must be computer savvy- able to navigate between screens

  • Must be able to read SOP’s to understand the process/procedures and be comfortable to make the appropriate decision to complete the appeal

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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

REQNUMBER: PS38505

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