Grievance​/Appeals Analyst II

Please note this is the target date and is subject to change. BCForward will send official notice ahead of a confirmed start date.

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.

Responsible for reviewing, analyzing and processing non-complex and some complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department 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.

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, and completion of the respective written communication documents to convey the determination.

The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.

The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses.

Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.

Identify opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed.

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.

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.

Contract to possible hire or extension

Monday-Friday

8AM-5PM

Occasional rotating Saturday and holiday coverage. Standard business hours Eastern Time. Schedule may be adjusted based on operational needs and approved coverage requirements.

Team members can expect to work approximately 1–2 Saturdays per month. When working a Saturday, they will receive a make-up day off during that same week.

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 be within a reasonable commute to a PulsePoint location.

Founded in 1998 on the idea…