Grievance/Appeals Representative I

Elevance Health•Woburn, MA

3d•$19 - $32•Hybrid

About The Position

Grievance/Appeals Representative I Hybrid 1: 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. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. Please note that per our policy on hybrid/virtual work, 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. The Grievance/Appeals Representative I will be responsible for reviewing, analyzing and processing claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement. How you will make an impact: 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. Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement. Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims. Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs. Identifies barriers to customer satisfaction and recommends actions to address operational challenges.

Requirements

HS diploma or equivalent.
Minimum of 1 year experience in health insurance business including customer service experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Good verbal and written communication, organizational, interpersonal skills and PC proficiency strongly preferred.

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.
Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.
Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.
Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
Identifies barriers to customer satisfaction and recommends actions to address operational challenges.