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Claims Appeals Specialist (myNEXUS)

Company: Anthem, Inc
Location: Modesto
Posted on: June 26, 2022

Job Description:


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, 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.

myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.

Job Summary:

The Claim Appeal Resolution Specialist is responsible for daily analysis, investigation and processing of disputed Medical Claims by performing an increased level of research, investigation and evaluation of billed claims data to ensure proper compliance, policy protocol and overall regulatory guidelines are met.


+ Performs research, investigation, negotiation and resolution of Provider Disputes and Appeals

+ Evaluates billing appropriateness, standard concepts, claim practices, and claim procedures.

+ Identifies provider trends through investigation and claim comparison

+ Reports and tracks all Appeal and Medical Records inventory received, assigned and completed

+ Coordinates daily with Claims and UM Teams on Appeal redeterminations

+ Communicates additional information requests to external customers to support redetermination case

+ Contributes to the development of department processes and procedures.

+ Provides final determination to the Claims Team for processing/re-processing of claims.

+ Assists with other responsibilities or duties as needed

+ Accepts additional assignments willingly.

Professional Requirements:

+ Adheres to dress code, appearance is neat and clean.

+ Completes annual education requirements.

+ Maintains patient confidentiality at all times.

+ Reports to work on time and as scheduled, completes work within designated time.

+ Follows all company policies related to time records.

+ Attends annual review and department in-services, as scheduled.

+ Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested.

+ Represents the organization in a positive and professional manner.

+ Actively participates in performance improvement and continuous quality improvement (CQI) activities.

+ Complies with all organizational policies regarding ethical business practices.

+ Communicates and demonstrates the mission, ethics and goals of the facility, as well as the focus statement of the department

Job Requirements

Educational & Experience Requirements

+ Bachelor Degree preferred or equivalent relevant work experience Certified Nurse Assistant or Medical Assistant certification preferred, or equivalent work experience

+ Knowledge of medical terminology, health insurance plans and medical billing concepts.

+ 3+ years of experience in a highly transactional Medical Claim Disputes and Appeals role.

+ Previous experience in a highly transactional production environment required.

Language Skills

+ Ability to read and communicate effectively in English.

+ Additional languages preferred.


+ Excellent written and oral communication skills.

+ Detail oriented with strong organizational and analytical skills.

+ The ability to manage multiple projects at one time.

+ Proficient in the use of office software products for e-mail, general word processing, data entry and basic calculations.

+ Self-starter with a high level of integrity and ability to work independently.

+ Ability to sit for extended periods and read monitors.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For , is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.


Keywords: Anthem, Inc, Modesto , Claims Appeals Specialist (myNEXUS), Other , Modesto, California

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