Remote Grievances & Appeals Specialist

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

Job summary

Elevance Health in California is seeking an entry-level Analyst in the Enterprise Grievance & Appeals Department to review, analyze and process non-complex grievances and appeals across multiple product types, including HMO, PPO, POS, and others.

You will work under guidance to research medical records, draft clear decisions, and coordinate with clinical staff, while adhering to accreditation standards.

Qualifications

• Requires a HS diploma or GED and a minimum of 3 years experience in grievances and appeals, claims, or customer service.
• Strong business writing proficiency and understanding of provider networks.
• Associates in this role should have strong oral, written and interpersonal communication, problem-solving, and analytical skills.
• Requires experience in Commercial Grievances & Appeals.
• Strong preference for Commercial HMO knowledge.

Responsibilities

• 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 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.

Skills

Communication

Customer Service

Claims

Grievances & Appeals

Education

HS Diploma or GED

Job description

Elevance Health in California is seeking an entry-level Analyst in the Enterprise Grievance & Appeals Department to review, analyze and process non-complex grievances and appeals across multiple product types, including HMO, PPO, POS, and others.

You will work under guidance to research medical records, draft clear decisions, and coordinate with clinical staff, while adhering to accreditation standards.