Anthem, Inc. UM Correspond Representative (myNEXUS) in Ocala, Florida
SHIFT: Day Job
Your Talent. Our Vision. At myNEXUS, a proud member of the Anthem, Inc. family of companies, 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.
myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness
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.
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.
Requires a high school diploma;
2 years of experience in a managed care delivery system and/or Utilization Management; or any combination of education and experience, which would provide an equivalent background.
Knowledge of the UM patient referral process, eligibility, benefits and Health Plan regulations, HMO/UM functions, ICD-9/CPT coding required.
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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.