Grievance/Appeals Analyst I (contract)

Elevance Health; Costa Mesa (CA); Hybrid; USD 30,000 - 41,000; Full time

Job summary

Elevance Health is seeking an entry level Analyst in the Enterprise Grievance & Appeals Department in California. The role focuses on reviewing non-complex grievances and appeals across multiple products, composing clear determinations, and coordinating with nursing/medical staff when needed.

The ideal candidate has a HS diploma or GED with 3 years in grievances/claims/customer service, strong writing, and knowledge of Commercial HMO processes.

Qualifications

• Strong oral, written and interpersonal communication skills.
• Experience in Commercial Grievances & Appeals.
• Demonstrated business writing proficiency and understanding of provider networks.

Responsibilities

• Reviews, analyzes and processes non-complex grievances and appeals per external accreditation and regulatory requirements.
• Researches and analyzes grievance/appeal issues using claims and medical records to determine a course of action.
• Drafts clear, written determinations and routes to appropriate medical staff when needed.
• Serves as a liaison between grievances & appeals and other internal departments.

Skills

Communication skills

Business writing

Grievances & Appeals experience

Interpersonal skills

Commercial HMO knowledge

Education

HS diploma or GED

Job description

Strong oral, written and interpersonal communication skills

Experience in Commercial Grievances & Appeals.

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.

This 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.

Primary duties may include, but are not limited to:

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.

Requirements:

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.

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.

Requires to already have experience in Commercial Grievances & Appeals.

Strong preference for Commercial HMO business knowledge.

Job Type:

Possible Temp To Hire

All candidates must reside in the State of California only.

The candidates can work flexible hours of that time frame (7:30-4pm, 8-4:30pm, or 9-5:30pm PST).

The candidates can work remotely. However, if they experience technical, training/coaching issue they must come into any unrestricted Pulse Point California office for assistance.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, contractors 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.

About BCForward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCForward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.

Pay Rate Range

Min Pay Rate $21.48

Max Pay Rate $29.7

Currency USD

Unit hourly

Additional Pay Rate Notes

The pay range is the range BCForward in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations.

Benefits Information

BCForward offers all eligible employees a comprehensive benefits package including, but not limited to major medical, HSA, dental, vision, employer-provided group life, voluntary life insurance, short-term disability, long-term disability, and 401k.

The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. This does not encompass additional non-standard compensation (e.g., benefits, paid time off, per diem, etc.).