Grievance & Appeal Analyst 1

About the role

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 members, providers, regulators and third parties across HMO, POS, PPO, EPO, CDHP and indemnity products, covering clinical and non‑clinical services, quality of service and quality of care issues, including executive and regulatory grievances.

Responsibilities

• Reviews, analyzes and processes non‑complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events, adapting written responses in clear, understandable language.
• Utilizes guidelines and review tools to conduct extensive research and analyze grievance and appeal issues, pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
• Follows department guidelines and tools to conduct reviews; the file review components of URAC and NCQA accreditations are must‑pass items.
• Analyzes and renders determinations on assigned non‑complex grievance and appeal issues and completes the respective written communication documents to convey the determination.
• Does not conduct utilization or medical management review activities requiring interpretation of clinical information.
• May serve as a liaison between grievances & appeals and/or medical management, legal, service operations and other internal departments.

Requirements

High school diploma or GED and a minimum of three years of experience working in grievances and appeals, claims, or customer service; or any equivalent combination of education and experience.

Skills

• Demonstrated business writing proficiency.
• Understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology.
• Strong oral, written and interpersonal communication skills.
• Problem‑solving, facilitation and analytical skills.

Benefits

In addition to salary, Elevance Health offers a comprehensive benefits package, incentive and recognition programs, equity stock purchase, and 401(k) contribution (all subject to eligibility requirements).

Pay

Salary range for this position (Nevada) is $19.92 to $24.90 per hour.

Schedule

Monday–Friday; virtual full‑time with required occasional in‑person training sessions.