Location: This position will work a remote model. Ideal candidates will live within 50 miles of a PulsePoint location.
The Grievance/Appeals Analyst II will be responsible for reviewing, analyzing and processing non-complex and some complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department from customer types (i.e. member, provider, regulatory, and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) 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:
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 and route to nursing and/or medical staff for review.
The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements.
As such, the analyst will strictly follow department guidelines and tools to conduct their reviews, and completion of the respective written communication documents to convey the determination.
The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses.
Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
Identify opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed.
Minimum Requirements
Requires a HS diploma or equivalent and a minimum of 1 year of Grievance & Appeals analyst experience.
Minimum of 3 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences
Associates degree preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For candidates working in person or remotely in the below locations, the salary* range for this specific position is $24.33/hr. to $36.50/hr.
Locations: Colorado
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
