Grievance/Appeals Rep II

Elevance Health; Massachusetts; Hybrid; USD 30,000 - 37,000; Full time

Job summary

Elevance Health in Massachusetts is seeking a Grievance/Appeals Representative II for a hybrid work arrangement, requiring in-office presence 1-2 days per week to foster collaboration while maintaining flexibility.

You will review and resolve grievances and appeals, contact customers to gather information, generate correspondence, and prepare case files for internal or external review, summarizing essential details for clinical staff and legal counsel.

Qualifications

• HS diploma or equivalent; 1 year of Grievance & Appeals analyst experience and 3 years in grievances/appeals, claims, or customer service.
• Three years in grievances and appeals, claims, or customer service; or an equivalent combination of education and experience.
• Strong organizational and communication skills; ability to manage multiple priorities.

Responsibilities

• Conduct investigations and review of customer grievances and appeals involving service and benefit issues.
• Contact customers to gather information and communicate case disposition; document interactions.
• Generate written correspondence to members, providers and regulatory agencies.
• Research administrative or non-clinical aspects of the appeal (eligibility, benefits, policy adherence).
• May decide on administrative appeals where guidelines are well documented.
• Prepare files for internal or external review by analysts, medical staff or consultants.
• Triages inquiries and prepares case files for committees/hearings.
• Summarize and present essential information for clinical staff or legal counsel.

Skills

Investigation

Communication

Documentation

Research

Case preparation

Triage

Education

HS diploma

Associates degree preferred

Tools

Microsoft Word

Excel

Database management

Job description

Shift: Monday-Friday

Grievance/Appeals Representative II

Shift: Monday-Friday

Location: Hybrid 1

This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Grievance/Appeals Representative II is responsible for reviewing, analyzing and processing policies related to claims events to determine the extent of the company's liability and entitlement.

How You Will Make An Impact

• 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.

Minimum Requirements

• 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.

Preferred Skills, Capabilities And Experiences

• 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.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $21.63 to $27.04.

Location

Massachusetts

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. 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.

• The salary range is the range Elevance Health 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. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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 should submit the Accessibility Accommodation Request Form and a member of the team will be in contact.

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.

Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.