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Utilization Management Correspondence Representative/Sr.- Norfolk, VA- PS22645 at Anthem, Inc.

Posted in Admin - Clerical 30+ days ago.

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Type: Full-Time
Location: NORFOLK, Virginia

Job Description:

Anthem, Inc. is the nation's leading health benefits company serving the needs of approximately 40 million medical members nationwide.

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.

Utilization Management Correspondence Representative/Sr.

This position may be filled at the Representative I or Representative Sr. level, depending on your skills and experience. Level will be determined by the hiring manager. 
Work Hours: Monday through Friday, between the hours of 9:00am – 5:30pm EST or 9:30am – 6:00pm EST; Overtime usually requested for the holidays and on weekends if the business need requires it

Location: This is an in-office position working ONLY from our 5800 Northampton Blvd Norfolk, VA 23502 office.

Responsible for processing and generating letters for services denied by the Utilization Management (UM) Medical Director within established Centers for Medicare and Medicaid Services (CMS) guidelines. This position is heavy Behavioral Health focused.

Primary duties may include, but are not limited to: 

  • Completes denial letters for services denied by Medical Director. 

  • Generates and prints denial letters for mailing. 

  • Provides feedback to ensure denials are handled according to CMS standards. 

  • Collaborates with other departments to produce letters for services denied in their respective units. 

  • Identifies opportunities to enhance workflow and offers solutions. 

  • Answers and routes incoming calls from providers, medical groups, and others verifying referral status. 

  • Maintains updated denial letter templates. 

  • Participates in department workgroups to improve processes and procedures

  • Researching authorizations and case notes to ensure accuracy of BH criteria and denial rationales.

Required Qualifications

  • Participates in department workgroups to improve processes and procedures

  • High school diploma or GED; 

  • Level I: 2 years of experience in a managed care delivery system and/or Utilization Management; 

  • Level Sr.: 2 years of experience as a Utilization Management Correspondence Rep, including 2 years of previous experience in a related field;

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

  • Knowledge of the Behavioral Health and Utilization Management patient referral process, eligibility, benefits and Health Plan regulations, HMO/UM functions, ICD-9/CPT coding

  • Skills: Extreme attention to details, flexibility, ability to multi-task and toggle between multiple systems, time-management, and the ability to function/produce in high demanding and production environment

  • Working knowledge of FACETS, MACESS, xPressions Iris Letter Hub, SharePoint, and Microsoft Office

  • Ability to work Monday through Friday, between the hours of 9:00am – 5:30pm EST or 9:30am – 6:00pm EST and overtime as required

Preferred Qualifications

  • Experience in the following:

    • Behavioral health and benefits

    • Working with Medical Directors and clinical staff

    • Call center

    • Building authorizations

    • Medicaid/Medicare

    • Dealing with sensitive cases 

  • Knowledge of CMS, and NCQA guidelines 

  • 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 An Equal Opportunity Employer/Disability/Veteran.