Note: The job is a remote job and is open to candidates in USA. Elevance Health is a healthcare company dedicated to improving lives and communities while simplifying healthcare. The Grievance/Appeals Analyst I reviews, analyzes, and processes non-complex grievances and appeals involving clinical and non-clinical services, claims, quality of service, and quality of care. The role researches records, renders determinations, prepares written communications, and coordinates with internal departments in accordance with regulatory and accreditation requirements.

Responsibilities

• 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
• The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation
• 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

Skills

• Requires a HS diploma or GED and a minimum of 3 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background
• Alternate locations may be considered if candidates reside within a commuting distance from an office
• Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law
• Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly preferred
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs (unless covered by a collective bargaining agreement)
• Medical benefits
• Dental benefits
• Vision benefits
• Short-term disability benefits
• Long-term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources
• Virtual full-time work, except for required in-person training sessions

Company Overview

Company H1B Sponsorship