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Grievance/Appeals Representative I - Mason, OH - PS16399 in Mason, OH at Anthem, Inc.

Date Posted: 1/8/2019

Job Snapshot

Job Description

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 benefits companies and a Fortune Top 50 Company.

Grievance/Appeals Representative I

This is a dedicated representative for the Complaints Tracking Module (CTM) Department.

Responsible for reviewing,analytical research, root cause analysis, and resolution of complaints received by Centers for Medicare/Medicaid Services (CMS) in accordance with policies and procedures of the department. 

Primary duties may include, but are not limited to: 
  • Conducts research and review of member/provider complaints involving but not limited to provision of service and benefit coverage issues.
  • Contacts members/providers to gather information and communicate disposition of case; documents interactions.
  • Generates written correspondence to customers such as members, providers and regulatory agencies.
  • Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.
  • Ensures appropriate resolution to complaints within specified time frames established by CMS and/or CTM Management.
  • Identifies barriers to members/providers satisfaction and recommends actions to address operational challenges. 

  • Requires a HS diploma or equivalent; 
  • 1+ years’ experience in Medicare health insurance business including customer service and complaints resolution experience;
  • Or, any combination of education and experience, which would provide an equivalent background.
  • Strong oral, verbal and written communication, organizational, time management, and interpersonal skills.
  • Strong analytical skills and root cause analysis skills.
  • Intermediate PC proficiency required. 

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 An Equal Opportunity Employer/Disability/Veteran