Grievance & Appeal Analyst 1

Elevance Health•St. Louis, MO

5d•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 may relate to clinical and non-clinical services, quality of service, and quality of care, including executive and regulatory grievances. This role enables associates to work virtually full-time, with flexibility and autonomy, except for required in-person training sessions. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

Requirements

Requires a HS diploma or GED 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.

Nice To Haves

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

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 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.
Strictly follows department guidelines and tools to conduct reviews, as the grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements.
Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completes the respective written communication documents to convey the determination.
Serves as a liaison between grievances & appeals and/or medical management, legal, and/or service operations and other internal departments.