Claims Appeals Specialist (myNEXUS)
Company: Anthem, Inc
Posted on: June 26, 2022
SHIFT: Day Job
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
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.
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.
DUTIES AND RESPONSIBILITIES:
+ 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
+ Reports and tracks all Appeal and Medical Records inventory
received, assigned and completed
+ Coordinates daily with Claims and UM Teams on Appeal
+ Communicates additional information requests to external
customers to support redetermination case
+ Contributes to the development of department processes and
+ 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.
+ 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
+ Follows all company policies related to time records.
+ Attends annual review and department in-services, as
+ 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
+ Actively participates in performance improvement and continuous
quality improvement (CQI) activities.
+ Complies with all organizational policies regarding ethical
+ Communicates and demonstrates the mission, ethics and goals of
the facility, as well as the focus statement of the department
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
+ Ability to read and communicate effectively in English.
+ Additional languages preferred.
+ Excellent written and oral communication skills.
+ Detail oriented with strong organizational and analytical
+ 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
+ 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 careers.antheminc.com. 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
Keywords: Anthem, Inc, Modesto , Claims Appeals Specialist (myNEXUS), Other , Modesto, California
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