Grievance/Appeals Rep II

Elevance Health•Woburn, MA

5d•Hybrid

About The Position

The Grievance/Appeals Representative II is responsible for reviewing, analyzing and processing policies related to claims events to determine the extent of the company's liability and entitlement. This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. 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 an accommodation is granted as required by law.

Requirements

Requires a HS diploma or equivalent
A minimum of 1 year of Grievance & Appeals analyst experience
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

Ability to organize work, set and manage multiple priorities in a time sensitive manner is strongly preferred.
Good oral and written communication skills, basic word processing, data base management, spreadsheet skills, PC proficiency and claims knowledge strongly preferred.
Behavioral health experience preferred.
Associates degree preferred.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
Contacts customers to gather information and communicate disposition of case; documents interactions.
Generates written correspondence to customers such as members, providers and regulatory agencies.
Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
Prepares files for internal or external review by analysts, medical staff or outside consultant.
Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.