Grievance/Appeals Analyst I (US)

Shift: Tuesday–Saturday. This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. Candidates must reside within a reasonable commuting distance from an office location unless accommodation is granted as required by law.

About the role

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 various customer types (member, provider, regulatory, and third party) and multiple products (HMO, POS, PPO, EPO, CDHP, and indemnity) related to 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 requiring adaptation of 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.
• Strictly follows department guidelines and tools to conduct reviews, ensuring compliance with URAC and NCQA accreditation standards (file review components are must-pass items).
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completes respective written communication documents to convey the determination.
• Excludes conducting any 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

• Requires a high school diploma or GED and a minimum of 3 years of 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 and Qualifications

• Demonstrated business writing proficiency.
• Understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology.
• For URAC-accredited areas, strong oral, written, and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills are expected.

Benefits

• Market-competitive total rewards including 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) with company match, stock purchase plan, life insurance, wellness programs, and financial education resources.

Schedule

This role follows a Hybrid Workforce Strategy, requiring associates to work at an Elevance Health location at least once per week, with specific requirements discussed during the hiring process.