[Hiring] Grievance/Appeals Representative I @Elevance Health

Role Description

The Grievance/Appeals Representative I is responsible for reviewing, analyzing, and processing claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Shift hours: 12:00pm - 8:00pm EST

How you will make an impact:

• Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
• Contacts customers to gather information and communicate disposition of case; documents interactions.
• Generates written correspondence to customers such as members, providers, and regulatory agencies.
• Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.
• Responds to appeals from CS Units, Provider Inquiry Units, members, providers, and/or others for resolution or affirmation of previously processed claims.
• Ensures appropriate resolution to inquiries, grievances, and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
• Identifies barriers to customer satisfaction and recommends actions to address operational challenges.

Qualifications

• HS diploma or equivalent.
• Minimum of 1 year experience in health insurance business including customer service experience; or any combination of education and experience which would provide an equivalent background.

Requirements

• Good verbal and written communication, organizational, interpersonal skills and PC proficiency strongly preferred.

Benefits

• Merit increases
• Paid holidays
• Paid Time Off
• Incentive bonus programs (unless covered by a collective bargaining agreement)
• Medical, dental, and vision benefits
• Short and long term disability benefits
• 401(k) + match
• Stock purchase plan
• Life insurance
• Wellness programs
• Financial education resources

Company Description

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.