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Anthem, Inc. Claims Auditor II/Sr (job family) in Las Vegas, Nevada

Description

SHIFT: Day Job

SCHEDULE: Full-time

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.

CLAIMS AUDITOR

LOCATION: This role is remote/work from home unless you are within an hour of the Minnetonka MN office.

Please note: This position will be filled at either the II or Sr level. The hiring manager will determine the appropriate level based upon the selected applicant's experience and skill set relative to the qualifications listed for this position.

LEVEL II

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 within Service Experience. Works 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.

LEVEL SR.

Responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types and products including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit.

Primary duties may include, but are not limited to:

  • Performs audits of and may adjudicate complex 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 complex system requests related to coding or system issues.

  • Refers overpayment opportunities to Recovery Team.

  • Serves as a subject matter expert for Policy and Clinical Guidelines.

  • Associates at this level serve as a mentor and resource to other audit staff.

Qualifications

LEVEL II

  • Must possess strong research and problem solving skills.

  • Requires a High School diploma or GED;

  • 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) with consistent above target performance;

  • Stop loss knowledge preferred

Working knowledge of insurance industry and medical terminology;

  • Detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines;

  • Ability to acquire and perform progressively more complex skills and tasks in a production environment

  • Or any combination of education and experience which would provide an equivalent background.

LEVEL SR.

  • Must possess strong research and problem solving skills.

  • Requires a high school diploma or GED;

  • 4+ years related experience in a quality audit capacity (preferably in healthcare or insurance sector) with consistent above target performance;

  • Stop loss knowledge preferred

  • Working knowledge of insurance industry and medical terminology;

  • Detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines;

  • Ability to acquire and perform progressively more complex skills and tasks in a production environment

  • Any combination of education and experience which would provide an equivalent background.

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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

REQNUMBER: PS37421

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