Grievance/Appeals Analyst II at Elevance Health

Cincinnati, Ohio, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

Requirements

HS diploma or equivalent
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)
Candidates must be within a reasonable commuting distance from the posting location(s), unless an accommodation is granted as required by law

Responsibilities

Review, analyze, and process non-complex and some complex pre-service and post-service grievances and appeals requests from various customer types (member, provider, regulatory, third party) and products (HMO, POS, PPO, EPO, CDHP, indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues, including executive and regulatory grievances
Utilize guidelines and review tools to conduct extensive research, analyze grievance/appeal issues, pertinent claims, and medical records to either approve or summarize and route to nursing/medical staff for review
Strictly follow department guidelines, tools, accreditation (URAC, NCQA), and regulatory standards for reviews and completion of written communication documents conveying determinations
Serve as a liaison between grievances & appeals and/or medical management, legal, service operations, and other internal departments, developing and maintaining relationships while instilling awareness of customer expectations
Identify opportunities for improvement
Provide support and assistance to G&A Analyst I associates as needed
Exclude conducting utilization or medical management review activities requiring interpretation of clinical information

Skills

Grievance Processing

Appeals Analysis

Claims Review

Medical Records Analysis

Regulatory Compliance

NCQA

URAC

Healthcare Guidelines

Customer Liaison

Elevance Health

Integrated health services and digital platform

About Elevance Health

Elevance Health focuses on enhancing the health of individuals throughout their lives by evolving from a traditional health benefits organization into a comprehensive health partner. The company serves over 118 million people, providing support at every stage of health through an integrated approach that addresses a wide range of health needs. Their services are backed by advanced capabilities and a digital health platform that streamlines access to care. Unlike many competitors, Elevance Health emphasizes a holistic view of health, aiming to redefine health and improve community well-being. The ultimate goal is to make health improvements accessible to everyone.

Indianapolis, IndianaHeadquarters

1944Year Founded

$309.4MTotal Funding

IPOCompany Stage

Enterprise Software, Social Impact, HealthcareIndustries

10,001+Employees

Benefits

Medical, dental, & vision insurance

401(k) + match

Paid holidays

Paid Time Off

Incentive bonus programs

Stock purchase plan

Life insurance

Wellness Programs

Financial education resources

Adoption & Surrogacy Assistance

Dependent-care Flexible Spending Account (DCFSA)

Parental Leave

Parental Transition Week

Critical Caregiving Leave

Risks

Departure of CFO John Gallina may create a gap in financial leadership.

Lawsuit against CMS over MA Star Ratings could lead to financial penalties.

CareBridge integration may face operational challenges, disrupting service delivery.

Differentiation

Elevance Health integrates whole health approach with digital health platform for comprehensive care.

Acquisition of CareBridge enhances home health services within Carelon division.

Strategic partnership with Clayton, Dubilier & Rice aims to innovate primary care delivery.

Upsides

AI integration in home health services can reduce hospital readmissions and improve outcomes.

Predictive analytics support early disease detection, aligning with Elevance's whole health approach.

Telehealth expansion offers opportunities to reach more patients remotely.

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