Grievance/Appeals Representative (Latham, NY)

Elevance Health•Latham, NY

1d•$20 - $24•Hybrid

About The Position

The Grievance/Appeals Representative I is an entry level position in the Enterprise Grievance & Appeals Department that 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. 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 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 equivalent and a 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.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills

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.