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Grievance/Appeals Analyst I

Company: Elevance Health
Location: Honolulu
Posted on: September 24, 2022

Job Description:

$500 Sign-On Bonus This is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests 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. Primary duties may include, but are not limited to:

  • Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
  • 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. The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
  • Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
  • Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
  • The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments. Minimum Requirements:
    • Requires a high school diploma or GED equivalent
    • 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:
      • Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly 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. $250 Referral Bonus Applicable to Colorado Applicants Only Hourly Pay Range*: $18.81/hr - $24.69/hr Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. * The hourly or 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. The Company may ultimately pay more or less than the posted range. This range is only applicable for jobs to be performed in Colorado. This range may be modified in the future. 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.

Keywords: Elevance Health, Honolulu , Grievance/Appeals Analyst I, Professions , Honolulu, Hawaii

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