Grievances & Appeals Representative
HumanaSalary not specified
Full Time
Junior (1 to 2 years)
Not SpecifiedCompensation
Mid-level (3 to 4 years), Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries
Requirements
- Bachelor’s degree and a minimum of 5+ years grievance & appeals experience
- Minimum of 3 years of management experience in the healthcare industry (or any combination of education and experience which would provide an equivalent background)
- Active unrestricted RN license (preferred)
- Must be within commutable distance to one of the listed locations: Ohio-Cincinnati, Columbus, Mason, or Seven Hills
Responsibilities
- Provides 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
- Coordinates Grievance and Appeals Committee Meetings and Member Panel Hearings
- Leads grievance and appeals in regulated audits
- 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
- 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
Skills
Key technologies and capabilities for this role
Questions & Answers
Common questions about this position
What is the salary range for this position?
For candidates working in Columbus, OH, the salary range is $82,720 to $124,080. In addition to salary, Elevance Health offers a comprehensive benefits package, incentive, and recognition.
Is this role remote or hybrid, and what are the location requirements?
This is a hybrid role requiring associates to be in-office 1-2 days per week in Cincinnati, Columbus, Mason, or Seven Hills, Ohio. Candidates must be within commutable distance to one of these locations, and those not within reasonable commuting distance will not be considered unless an accommodation is granted.
What are the minimum requirements for this role?
A 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 are required, or any combination of education and experience which would provide an equivalent background. An active unrestricted RN license is preferred.
What benefits does Elevance Health offer?
Elevance Health offers a comprehensive benefits package, incentive, and recognition in addition to salary.
What experience makes a strong candidate for this Manager II role?
Strong candidates will have a Bachelor’s degree, 5+ years of grievance and appeals experience, 3+ years of management experience in healthcare, and an active unrestricted RN license.
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