Medical Review Spec, I, II

at Anthem, Inc in Wilmington, Delaware, United States

Job 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 care companies and a Fortune Top 50 Company.

Responsible for reviewing and analyzing institutional and professional claims and supporting medical documents to determine medical necessity of billed services and benefits payable according to established guidelines.

Primary duties may include, but are not limited to:

• Perform post decision clinical and nonclinical activities for all requested Home Health Services included as contracted services that meet eligibility and benefits coverage.

• Prepares written summaries for the most complex cases requiring higher level review.

• Reviews, analyzes and renders determinations on requests from the providers and beneficiaries for reconsideration of previously rendered medical decisions relating to claims issues.


Minimum Requirements: • Requires a Therapy or Nursing License.. • A minimum of 3 years of health care experience; or any combination of education and experience which would provide an equivalent background.

Preferred Qualifications: • Home Health Care experience preferred.

• Current unrestricted RN, LPN, OT, PT, OTA, PTA license in applicable state(s) preferred.

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 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.

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Job Posting: JC194092146

Posted On: Oct 06, 2021

Updated On: Oct 21, 2021