SCA Appeals Representative Sr.

Elevance Health•Tampa, FL

1d•Remote

About The Position

The SCA Appeals Representative Sr. investigates and reviews customer appeals regarding provision of service and benefit coverage issues. This position triages clinical and non-clinical inquiries, grievances, and appeals; prepares case files for member grievance committees and hearings; and summarizes and presents information to clinical specialists, medical directors, and legal counsel. The representative responds to oral and written complaints, works with customers to gather information and communicate case dispositions, and documents case activity in tracking systems. Under minimal supervision, the role resolves inquiries, grievances, and appeals involving non-clinical services and quality-of-service issues across customer and product types. It handles complex issues requiring extensive research or adapted responses, investigates and recommends resolutions for non-clinical cases, makes administrative exceptions within prescribed guidelines, and ensures cases are resolved within applicable regulatory, accreditation, or customer timeframes. The role also identifies customer-satisfaction barriers, recommends operational improvements, assists other appeals staff, and provides guidance and leadership to team members. The role is described as virtual full-time, with in-person training sessions required. Candidates must reside within a reasonable commuting distance of a posting office unless an accommodation is granted as required by law. As part of the Wellpoint Federal division, foreign national applicants must have lived in the United States for at least three of the past five years.

Requirements

High school diploma or equivalent, and at least 4 years of related experience working in grievances and appeals; or an equivalent combination of education and experience.
For foreign national applicants to the Wellpoint Federal division: residency in the United States for at least three of the past five years.

Nice To Haves

Understanding of the application of benefits contracts, pricing, policies, and legislative regulations.
Verbal and written communication skills.
Organizational skills.
Interpersonal skills.
PC proficiency.
Strong appeals knowledge.
Knowledge of Medicare Parts A and B.

Responsibilities

Triage clinical and non-clinical inquiries, grievances, and appeals.
Prepare case files for member grievance committees and hearings.
Summarize and present essential information to clinical specialists, medical directors, and legal counsel.
Respond to oral and written complaints.
Resolve inquiries, grievances, and appeals within regulatory, accreditation, and customer timeframes.
Contact customers to gather information and communicate case dispositions, and document interactions.
Generate written correspondence to members, providers, and regulatory agencies.
Identify barriers to customer satisfaction and recommend actions to address operational challenges.
Pursue ongoing education and training on benefits and services, and document and log inquiry, appeal, and grievance information in tracking systems.
Resolve non-clinical service and quality-of-service inquiries, grievances, and appeals under minimal supervision.
Research and adapt responses to complex customer issues.
Make administrative exceptions within prescribed guidelines.
Investigate, summarize, and make recommendations for non-clinical cases.
Seek, evaluate, and understand information needed to make effective decisions.
Assist other grievance and appeals staff with file decisions.
Provide direction and guidance to other team members, foster a supportive environment, and provide leadership.
Perform other related duties as required.