SCA Appeals Rep I (US)
Elevance Health - South Portland, ME
posted 12 days ago
About the position
The SCA Appeals Representative I position is an entry-level role in the NGS Appeals Department that reviews, analyzes, and processes non-complex pre-service and post-service grievances and appeals requests from various customer types, including members, providers, regulatory bodies, and third parties. The position requires adherence to external accreditation and regulatory requirements, as well as internal policies. The analyst will conduct extensive research and analyze grievance and appeal issues, utilizing guidelines and review tools to determine outcomes and communicate decisions effectively. Responsibilities exclude conducting any utilization or medical management review activities that require the interpretation of clinical information. The analyst may also serve as a liaison between grievances and appeals and other internal departments.
Responsibilities
- Reviews, analyzes, and processes non-complex grievances and appeals according to accreditation and regulatory requirements.
- Utilizes guidelines and review tools to conduct extensive research and analyze grievance and appeal issues.
- Renders determinations on assigned non-complex grievance and appeal issues and completes written communication documents to convey the determination.
- Strictly follows department guidelines and tools to conduct reviews.
- Serves as a liaison between grievances & appeals and other internal departments.
Requirements
- High school diploma or GED required.
- Up to 2 years of experience in grievances and appeals, claims, or customer service, or a combination of education and experience that provides an equivalent background.
- Must have lived in the United States for at least three of the past five years.
Nice-to-haves
- Familiarity with medical coding and medical terminology.
- Demonstrated business writing proficiency.
- Understanding of provider networks and the medical management process.
- Knowledge of claims processes and internal business processes.
Benefits
- Comprehensive benefits package
- Incentive and recognition programs
- Equity stock purchase
- 401k contribution
- Paid holidays
- Paid Time Off
- Medical, dental, and vision benefits
- Short and long-term disability benefits
- Life insurance
- Wellness programs
- Financial education resources
