SCA Appeals Rep II

Elevance Health•Denison, TX

23h•Remote

About The Position

SCA Appeals Rep II Virtual: 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. Alternate locations may be considered if candidates reside within a commuting distance from an office 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. Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations. The SCA Appeals Rep II is responsible for reviewing, analyzing, and processing policies related to claims events and determining the company's liability and entitlement.

Requirements

Requires high school diploma or equivalent and a minimum 2 years related experience such as customer service in a managed care, medical office, or health insurance environment; or any combination of education and/or experience which would provide an equivalent background
This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants to meet the residency requirement of living in the United States for at least three of the past five years.

Nice To Haves

Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals strongly preferred.
Claims knowledge as well as strong oral and written communication skills preferred.
Ability to organize work, set and manage multiple priorities in a time sensitive manner preferred.
Basic word processing, database management, and spreadsheet skills 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.
Researches administrative or non-clinical aspects of the appeal (i.e., eligibility, benefit levels, overall adherence to policies and practices).
May make decisions on administrative appeals where guidelines are well documented and involve limited discretion.
Prepares files for internal or external review by analysts, medical staff or outside consultant.
Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
Responds to oral and written complaints.
Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
Under minimal supervision resolves inquiries, grievances and appeals requests from customer types (i.e., member, provider, and regulatory) and multiple products (i.e. HMO, POS, and PPO) related to non-clinical services and quality of service issues.
Handles non-routine customer issues requiring adaptation of response or extensive research.
Exercises judgment within set guidelines.
Identifies barriers to customer satisfaction and recommends actions to address operational challenges.