27 Aug
SCA Appeals Representative I- PS38517
California, Applevalley 00000 Applevalley USA

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 varyAttendance 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 shiftHourly rates are non-negotiable:Broward

County, FL15.02Bryan

County, OK14.30Cincinnati,

OH14.49Cooke

County, TX13.56Denison,

TX14.47Harrisburg,

PA15.01Hingham,

MA16.46Indianapolis,

IN14.45Kanawha

County, WV13.32Lamar

County, TX13.80Louisville,

KY13.92Manchester,

NH15.63Mason

County, OH13.97Milwaukee,

WI15.40Philadelphia,

PA14.68Pinal

County, AZ13.78Richmond,

VA13.85South

Portland, ME15.26Syracuse,

NY13.87Requires 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

Review 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: PS38517

Vacancy expired!


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