Anthem Inc. Medical Jobs

Job Information

Anthem, Inc. G&A Risk Analyst II in Mason, Ohio


SHIFT: Day Job

SCHEDULE: Full-time

G & A Risk Analyst I or II

Location: Office-based preferred, possible remote opportunity for these locations;

Midland, GA - Indianapolis, IN - Mason, OH - Albany, NY - Wallingford, CT - VA cities within 50 miles of an Anthem office

This position is posted as a job family and the selected candidate will be placed into the job level commensurate with their experience

Responsible for providing support services for multiple states, enterprise-wide functions and/or complex issues through complex assignments and projects, which utilize recognized areas of specialization and knowledge specific to the company.

G/A Risk Analyst I

Entry level position in the Enterprise Grievance & Appeals Department.

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.

G/A Risk Analyst II

Primary duties may include but are not limited to;

  • Prepares, analyzes and evaluates written correspondence such as complaints, grievances, document demands, alleged ERISA violations and researches to resolve problems and close outstanding issues at the state or enterprise level.

  • Conducts research and analysis, recommends appropriate course of action and next steps.

  • Performs fact checking, gathers documents, researches and responds to records requests, and various inquiries from internal and external sources, coordinates investigative and discovery activities specific to Grievance and Appeal functions.

  • Assists with compliance issues as needed.

  • Attends and represents Grievances & Appeals at appropriate legal proceedings and arbitration hearings under supervision of counsel.

  • Participates on projects and may participate in negotiations and strategizing with business and staff. Enters information as required into appropriate databases or other document management systems.

  • May serve as a resource to other support staff.


Qualifications - Internal

Additional Experience:

  • Experience with WGS and NASCO required.

  • Experience with Facets, CS90 and ACES preferred.

  • Experience with NextGen required.

  • Experience with appeals, including out-of-network claims, pricing and reimbursement, is a plus!

  • Claims experience required.

  • Compliance experience preferred.

  • G/A Risk Analyst I

Requires a High school diploma or GED; 3 to 5 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, the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background.

G/A Risk Analyst II

Requires 5 years of related experience or any combination of education and experience, which would provide an equivalent background. BA/BS in a related field is preferred. Paralegal certification and experience preferred.

For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

An Equal Opportunity Employer /Disability /Veteran

REQNUMBER: PS45195-Mason-Mason