Grievance/Appeals Rep II

• Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
  
• Contacts customers to gather information and communicate disposition of case; documents interactions.
  
• Generates written correspondence to customers such as members, providers and regulatory agencies.
  
• Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
  
• May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
  
• Prepares files for internal or external review by analysts, medical staff or outside consultant.
  
• Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
  
• Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
  

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

• Ability to organize work, set and manage multiple priorities in a time sensitive manner is strongly preferred.
  
• Good oral and written communication skills, basic word processing, data base management, spreadsheet skills, PC proficiency and claims knowledge strongly preferred.
  
• Behavioral health experience preferred.
  
• 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.
  

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.

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 and Influenza. 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 View email address on aplitrak.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act