NGS Appeals Rep I (Milwaukee, WI) 67369 IF
WellPoint 674 reviews - Milwaukee, WI

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An independent subsidiary of WellPoint, Inc, National Government Services (NGS) is a national leader in government health programs. NGS is one of the largest Medicare contractors in the country and has served as a Medicare contractor since 1966.

Bring your expertise to our innovative, performance-focused culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.

This is an entry level position in the NGS Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (Part A & B) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. Primary duties may include, but are not limited to: Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Job Qualifications

Requires a High school diploma or GED; up to 2 years experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, WellPoint internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background. Appeals experience preferred. Strong reading comprehension required. Claims processing and/or Customer Service experience a plus. Medicare / Medicare system experience a preferred.

WellPoint is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine, and is a 2012 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).

*Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.

*WARNING : Please beware of phishing scams that promote work-at-home opportunities and may also pose as legitimate companies. Please be advised that a WellPoint recruiter will never ask you for a credit card or 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 on our web site.

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674 reviews
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