Responsible for leading and coaching a team of Grievance & Appeals Analysts in the Enterprise Grievance & Appeals Department responsible to review, analyze and process preservice and post service grievances and appeals requests related to clinical and non-clinical services, quality of service and quality of care issues to include executive and regulatory grievances.
Primary duties may include, but are not limited to:
- Monitors workflow and makes assignments to ensure the correct team resource is utilized to achieve accreditation and regulatory compliance metrics in a quality manner.
- May also be responsible to provide review and analysis of complex preservice and post service grievances and appeals requests from customer and multiple products related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
- Coaches, trains, and audits to ensure the team correctly 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.
- HS diploma or equivalent
- Minimum of 3 years of Grievance & Appeals Senior analyst experience; or any combination of education and experience which would provide an equivalent background.
- Associate's or BA/BS degree.
- WGS, NEXTGEN, ACMP and Solutions Central experience.
- Strong organizational and communication skills.
- Claims, insurance, medical and clinical experience.
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 $25.54 hr. to $45.97 hr.
Locations: California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY
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.