Anthem Looking for Claims Auditor II at Jacksonville, FL Full Time

Description

SHIFT: Day Job

SCHEDULE: Full-time

Be part of an extraordinary team

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

Build the Possibilities. Make an extraordinary impact.

Simply Healthcare Plans, Inc. is a proud member of Anthem’s family of brands. We are a licensed health maintenance organization with health plans for people enrolled in Medicaid and/or Medicare programs in Florida.

• Must be located in the state of Florida.
• This position will be primarily work from home.

How you will make an impact:

To ensure consistent use of this job across the enterprise, please consult with your Human Resources partner prior to using this job (HRBP should work with Compensation). Responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types and products including specialized claims, working independently and without significant guidance. Primary duties may include, but are not limited to:

• Performs audits of and may adjudicate high dollar claims while maintaining acceptable levels of claims inventory and age.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates basic and complex system requests related to coding or system issues.
• Refers overpayment opportunities to Recovery Team.
• Independently interprets Medical Policy and Clinical Guidelines.

Qualifications

Minimum Requirements:

• High school diploma or GED equivalent
• Minimum of 5 years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred. Strong research and problem solving skills preferred.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.

Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact [email protected] for assistance.