Anticipated End Date:

2024-10-11

Position Title:

Grievance/Appeals Analyst II

Job Description:

Title: Grievance/Appeals Analyst II

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.

The Grievance/Appeals Analyst II will be responsible for reviewing, analyzing and processing non-complex and some complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department from customer types (i.e. member, provider, regulatory, and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

How you will make an impact:

• 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, and completion of the respective written communication documents to convey the determination.
• The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
• The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
• Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• Identify opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed.

Minimum Requirements

• Requires a HS diploma or equivalent and a minimum of 1 year of Grievance & Appeals analyst experience.
• 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.

Preferred Skills, Capabilities and Experiences

• Associates degree preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Job Level:

Non-Management Non-Exempt

Workshift:

Job Family:

CLM > Claims Support

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

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.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.