Location: Open to any location but must meet the hybrid workplace model requirement.
Elevance Health supports a hybrid workplace model (virtual and office) with PulsePoint sites used for collaboration, community, and connection, with the minimum in-office commitment being 1-3 days in an office per week.
Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.
Responsible for management oversight of grievances and appeals departmental units to investigate, resolve, and respond to grievances and appeals, manages inventory and production levels, and operational and plan risk, ensures quality, and regulatory compliance.
PRIMARY DUTIES:
Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings.
Leads grievance and appeals in regulated audits.
Analyzes large data sets using advanced knowledge of ETL data processing methods.
Designs and builds ad hoc and recurring reports and data visualizations using data modeling tools like Power Pivot.
Develops predictive models to forecast business needs and meet key objectives.
Serves as a resource for complex issues and interpretation of claims, provider contracts and data, eligibility, member contracts, benefits, clinical decisions, pharmacy on pre-service and post service appeals and grievances related to non-clinical and clinical services, quality of service and quality of care issues including executive and regulatory grievances.
Oversees and implements new subsystems, procedures, techniques and supports digital automation objectives.
Architects SharePoint lists and manages permissions to meet user needs using site governance best practices.
Analyzes and develops strategies by achieving performance thresholds within budgetary guidelines.
Monitors trends and analyzes grievance and appeals data to identify and recommend plan and policy changes and to ensure state and federal regulatory compliance and resolution within the regulatory timeframes.
Ensures programs support overall QI program and meet regulatory compliance/accreditation and the company standards.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Minimum Requirements: Bachelor's degree and a minimum of 5+ years grievance & appeals experience and a minimum of 3 years of management experience in the healthcare industry; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experience:
Advanced knowledge of ETL data processing using query language such as SQL or Power Query.
