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Grevance & Appeals Auditor I REMOTE- PS22159Location: United StatesNewRequisition #: PS22159Your 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
benefits companies and a Fortune Top 50 Company.The Grievance/Appeals Auditor I is responsible for post completion examination of grievances and appeals in multiple states.Primary duties may include, but are not limited to:
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.
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.
Working knowledge with the following: Medicare, Pega, CMS Regulations,Facets, o Infopath
Vacancy expired!