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Grievance & Appeals Coordinator - Norfolk, VA - PS16296

PS16296 Requisition #
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Your Talent. Our Vision. At Amerigroup, a proud member of the Anthem, Inc. family of companies focused on serving Medicaid, Medicare and uninsured individuals, 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 health care. 

This is an exceptional opportunity to do innovative work that means more to you and those we serve.  

Grievance and Appeals Coordinator

Responsible for investigating and reviewing customer grievances and appeals regarding provision of service and benefit coverage issues. 

Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings. 

Primary duties may include, but are not limited to: 
  • Summarizes and presents essential information for the clinical specialist or medical/dental director and legal counsel. 
  • Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President complaints. 
  • Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs. 
  • Contacts members to gather information and communicate disposition of case; documents interactions. 
  • Generates written correspondence to members, providers and regulatory agencies. 
  • Identifies barriers to customer satisfaction and recommends actions to address operational challenges. 
  • Pursues ongoing education/training on benefits/services to ensure accurate resolution of grievances and appeals, and overall industry knowledge and development (i.e. HIAA, LOMA, etc.). 
  • Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database. 

  • Requires a HS Diploma or equivalent;
  • 4 years progressively complex experience working in grievances and appeals; 
  • Or, any combination of education and experience, which would provide an equivalent background.
  • Ability to multi-task, detail-oriented, ability to function in a production-based and independent work environment
Preferred Qualifications:
  • Behavioral Health experience – call center or external
  • Ability to meet quality standards in a high-demand BH shared services department 
  • PEGA familiarity 
  • Systems experience proficiency – FACETS, MACESS 
  • MS Office (Word, Excel, Outlook) proficiency 
  • Experience working with Medical directors and clinical staff 
  • Experience building authorizations and claims experience 
  • Medicaid/Medicare experience 
  • Bilingual 
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.

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Work alongside some of the most skilled actuarial professionals in the business. Our underwriting team has opportunities available in pre-sales, retention and iimplementation, risk analysis, life and disability underwriting, and medical evidence underwriting.

Anthem Underwriting associates collaborate with some of the most skilled actuarial professionals in the business. Join us as we apply advanced research and risk analysis to deliver solutions that positively impact lives of consumers .

  • Work across life and disability underwriting, pre-sales, retention and implementation, risk analysis and medical evidence underwriting
  • Combine out-of-the-box thinking and solid analytical skills to generate innovative, life-enhancing solutions
  • Partner with sales professionals to write profitable business that achieves enterprise-wide goals
  • Accurately assess risk and craft coverage plan proposals that meet the needs of both the Company and its members

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