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Grievance/Appeals Representative I

  • Job Family: Claims
  • Type: Full time
  • Date Posted:
  • Req #: JR44465

Location:

  • OH, Mason

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Description

Must be located in Mason, OH. This is NOT a work from home position, this position will be working in the Mason, OH office.

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.

Primary duties may include, but are not limited to:

  • 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.

Minimum Requirements:

  • High school diploma or GED equivalent

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

  • Must be able to work in Mason, OH office

Preferred Skills, Capabilities and Experiences:

  • Claims experience preferred.

  • Experience within Elevance Health and knowledge of company software preferred.

  • ​Good verbal and written communication, organizational, interpersonal skills

  • PC proficiency strongly preferred and experience with 2 monitors preferred.


Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

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