SCA Appeals Representative I

Elevance Health•Indianapolis, IN

1d•Remote

About The Position

This role enables associates to work virtually full-time, except for 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 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 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.

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 Wellpoint Federal 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.