SCA Appeals Representative I

Elevance Health•Tampa, FL

1d•Remote

About The Position

The SCA Appeals Representative I reviews, analyzes, and processes non-complex pre- and post-service grievances and appeals requests from members, providers, regulatory parties, and third parties across Part A and B products. Issues may involve clinical and non-clinical services, quality of service, quality of care, and executive or regulatory grievances. This virtual full-time role requires in-person attendance for training sessions. Applicants must live within a reasonable commuting distance of a posting location unless an accommodation is granted as required by law. The position is within Wellpoint Federal, a subsidiary of Elevance Health that supports federal programs through claims administration, data, and care delivery services. The role requires a high school diploma or GED and at least one year of experience in grievances and appeals, claims, or customer service, or an equivalent combination of education and experience. Because this position is part of Wellpoint Federal, foreign national applicants must have lived in the United States for at least three of the past five years, as required by CMS TDL 190275.

Requirements

High school diploma or GED, or an equivalent combination of education and experience.
At least 1 year of experience working in grievances and appeals, claims, or customer service, or an equivalent combination of education and experience.
Foreign national applicants 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.
Business writing proficiency.
Understanding of provider networks, the medical management process, the claims process, internal business processes, and internal local technology.
Knowledge of Part A and B Medicare.

Responsibilities

Review, analyze, and process non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies, and claims events requiring written responses.
Use guidelines and review tools to research and analyze grievance and appeal issues, including relevant claims and medical records, to approve requests or prepare summaries.
Route summaries and information to nursing and/or medical staff for review, following department guidelines and tools.
Serve as a liaison between grievances and appeals and/or medical management, legal, service operations, and other internal departments.