Job Details

Grievance/Appeals Rep I, Miami, FL – 127562



April 21, 2017


Simply Healthcare

Your Talent. Our Vision. At Simply Healthcare, a proud member of the Anthem, Inc. family of companies, it’s a powerful combination and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. We are a Florida licensed health maintenance organization that serves individuals enrolled in Medicaid and/or Medicare programs, 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.

Grievance/Appeals Representative I

Responsible for reviewing, analyzing and processing grievances in accordance with policies.

Primary duties may include, but are not limited to:

* Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
* Contacts customers to gather information and communicate disposition of case; documents interactions.
* Generates written correspondence to customers such as members, providers and regulatory agencies.
* Performs research to respond to inquiries and interprets policy provisions to determine the extent of company’s liability and/or provider’s/beneficiaries entitlement.
* Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.
* Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
* Identifies barriers to customer satisfaction and recommends actions to address operational challenges.


* Requires a High School diploma/GED
* 1-3 years experience in health insurance business including customer service experience
* Any combination of education and experience, which would provide an equivalent background
* Good verbal and written communication, organizational and interpersonal skills
* Bilingual in English-Spanish preferred
* Managed Care experience required
* PC proficiency preferred
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2016 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at EOE. M/F/Disability/Veteran.

*WARNING : Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that an Anthem recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our careers require that you first complete an online application.