Anthem In. Case Management Jobs

Job Information

Anthem, Inc. Medical Policy Analyst in Fond du Lac, Wisconsin


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At AIM Specialty Health (AIM) , a proud member of the Anthem, Inc. family of companies, 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.

Job Description:

Responsible for medical research and developing criteria for medical policies to be used by review, utilization, and case management nurses.

Primary duties may include, but are not limited to:

  • Researches and evaluates medical claim issues against local and national Medicare policy guidelines.

  • Reviews new and updated codes for accuracy and consistency.

  • Researches relevant studies and reviews articles for the development of local medical review policies and for responses to inquiries from providers.

  • Works with Medical Directors on the development of local medical review policies.

  • Assists operations by reviewing the complex and non-standard types of claims as related to a policy.

  • Codes changes into claims systems using national coding structure for processing accuracy and clinical appropriateness once the medical policy has been established by physician plan committee.

  • Serves as a liaison to business units for correct coding of claims.

  • Researches questions and issues from internal physicians and nurses as they relate to developed medical policies.

  • Responds to internal and external requests that seek written clarification of a general or specific policy question.

  • The response may be reiteration of an established policy, a redefinition of the current policy, or research to determine a new or revised policy.

    Additional responsibilities may include:

  • Researches and evaluates health plan medical policy rules for new client implementations.

  • Develop clinical algorithms used in the implementation process for client medical policy review.

  • Works with Medical Directors on development of strategies and process to enhance and expedite the clinical implementation of new clients, new medical policies, and updated coverage determinations.

  • Assists operations by serving as a liaison to the clinical team and the clinical content vendor.

  • Reviews reporting from clinical content vendor related to medical policy updates.

  • Participates in oversight and testing processes of clinical system.


The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Anthem approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.

Required Qualifications:

  • Requires a BA/BS degree and a minimum of 2 years related experience including clinical experience and may include operations experience; or any combination of education and experience which would provide an equivalent background.

  • Typically requires an active state RN license.

  • Travel may be required.

    Preferred Qualifications

  • Nursing degree preferred.

  • Background in and/or a certification in clinical informatics is preferred.

  • Excellent Computer skills are highly desirable.

  • Oncology background or experience with oncology medical policy review is critical and highly desirable.

    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 Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Applicants who require accommodation to participate in the job application process may contact for assistance.

    REQNUMBER: PS65011-Wisconsin