Manager II Grievance/Appeals

Elevance Health•Atlanta, GA

2d•$79,876 - $151,344•Hybrid

About The Position

The Manager II Grievance/Appeals will be responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance. This role requires associates to be in-office 3 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 Bachelor's degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

Experience with medical necessity appeals.
Medicaid and Commercial experience.
Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Responsibilities

Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings.
Leads grievance and appeals in regulated audits.
Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances.
Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives.
Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines.
Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes.
Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.