Grievance/Appeals Analyst I

Elevance Health; Indianapolis (IN); Hybrid; USD 80,000 - 100,000; Full time

Job summary

An established industry player is seeking a Grievance/Appeals Analyst I to join their dynamic team. In this entry-level role, you will have the opportunity to make a significant impact by reviewing and processing grievances and appeals requests. Your keen analytical skills and attention to detail will be essential as you navigate the complexities of customer service in the healthcare sector. This hybrid position allows you to work both remotely and in the office, providing flexibility while you develop your expertise in the field. If you are passionate about making a difference and have a strong foundation in customer service, this role is perfect for you.

Qualifications

• HS diploma or GED required with 3 years experience in grievances, appeals, or claims.
• Strong communication and analytical skills are essential.

Responsibilities

• Review, analyze, and process non-complex grievances and appeals.
• Conduct extensive research and analyze claims and medical records.

Skills

Business Writing Proficiency

Interpersonal Communication Skills

Problem-Solving Skills

Analytical Skills

Education

High School Diploma or GED

Tools

Claims Processing Tools

Medical Records Systems

Job description

Title: Grievance/Appeals Analyst I

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 I is an entry-level position in the Enterprise Grievance & 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 (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:

• 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.

Minimum Requirements

• HS diploma or GED
• 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

• 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 highly preferred.

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.