Grievance/Appeals Analyst I (US)

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 involves reviewing, analyzing, and processing 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 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.
Understanding of the medical management process.
Understanding of the claims process.
Understanding of the company's internal business processes.
Understanding of 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 response 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 completion of the respective written communication documents to convey the determination.
May serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.