SCA Appeals Representative I

The SCA Appeals Rep I is responsible for reviewing, analyzing, and processing non-complex pre and post-service grievances and appeals requests from various customer types and multiple products. This includes clinical and non-clinical services, quality of service, and quality of care issues, such as executive and regulatory grievances.

Responsibilities

• Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, as well as internal policies and claims events requiring written responses.
• Utilizes guidelines and review tools to conduct extensive research and analysis of the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize.
• Routes summaries and information to nursing and/or medical staff for review.
• Strictly follows department guidelines and tools to conduct reviews.
• Serves as a liaison between grievances & appeals and/or medical management, legal, and/or service operations and other internal departments.

Requirements

• High school diploma or GED with a minimum of 1 year experience working in grievances and appeals, claims, or customer service; or any combination of education and/or experience which would provide an equivalent background.
• This position is part of Wellpoint Federal, a subsidiary of Elevance Health, which requires foreign national applicants to live in the United States for at least three of the past five years.

Preferred Experience, Skills, And Capabilities

• Familiarity with medical coding and medical terminology.
• Demonstrated business writing proficiency.
• Understanding of provider networks, the medical management process, claims process, all of the company's internal business processes, and internal local technology.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

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.

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. 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 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 may contact elevancehealthjobssupport@elevancehealth.com for assistance.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws. Applicants required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.