Grievance and Appeals Analyst I

Elevance Health•St. Louis, MO

1d•Remote

About The Position

The Grievance/Appeals Analyst I is an entry-level position in the Enterprise Grievance & Appeals Department. This role 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). The issues addressed include clinical and non-clinical services, quality of service, and quality of care, encompassing executive and regulatory grievances.

Requirements

Requires a HS diploma or GED.
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.

Nice To Haves

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

Responsibilities

Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies, and claims events.
Adapts written responses in clear, understandable language.
Utilizes guidelines and review tools to conduct extensive research and analyze grievance and appeal issues, as well as pertinent claims and medical records.
Summarizes and routes information to nursing and/or medical staff for review when necessary.
Strictly follows department guidelines and tools to conduct reviews, as the work is subject to applicable accreditation and regulatory standards.
Analyzes and renders determinations on assigned non-complex grievance and appeal issues.
Completes respective written communication documents to convey determinations.
Serves as a liaison between grievances & appeals and/or medical management, legal, and/or service operations and other internal departments.