SCA Appeals Rep I

Elevance Health • Denison, TX

5d • Hybrid

About The Position

SCA Appeals Representative I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. 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. National Government Services is a proud member of Elevance Health's family of brands. We administer government contracts for Medicare and partner with the Centers for Medicare and Medicaid Services to transform federal health programs. The SCA Appeals Rep I is Responsible for reviewing, analyzing, and processing non-complex pre and post service grievances and appeals requests from customer types (i.e., member, provider, regulatory, and third party) and multiple products (Part A & B) which are related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. How you will make an impact: Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements as well as internal policies and claims events requiring written responses. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize. Routes summaries and information to nursing and/or medical staff for review. Strictly follows department guidelines and tools to conduct reviews. Serves as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Requirements

• Requires a High school diploma or GED and a minimum of 1 year experience working in grievances and appeals, claims, or customer service; or any combination of education and/or experience which would provide an equivalent background.
• This position is part of our NGS (National Government Services) division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States 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, the medical management process, claims process, all of the company's internal business processes, and internal local technology strongly preferred.

Responsibilities

• Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements as well as internal policies and claims events requiring written responses.
• Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize.
• Routes summaries and information to nursing and/or medical staff for review.
• Strictly follows department guidelines and tools to conduct reviews.
• Serves as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees