Behavioral Health Appeals Coordinator Lead

Description

Behavioral Health Appeals Coordinator Lead - Government Business Division

*This role will be required to work the occasional weekend and holiday*

Location: This position will work a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.  

The Behavioral Health Appeals Coordinator Lead is responsible for serving as a team lead and for investigating and processing the most complex grievances and appeals requests from members and providers related to behavioral health services. Serves as a technical resource to team and may be assigned to work on projects in support of medical policy and/or managed care initiatives.

How you will make an impact:

• Investigates and reviews member and provider grievances and appeals.

• Works on issues that are of a complex nature.

• Serves as an internal resource for lower-level behavioral health appeal coordinators and staff.

• Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.

• Extrapolates and summarizes medical information for medical directors, consultants, and other external review.

• Prepares recommendations to either uphold or deny appeal and forwards to medical director for approval.

• Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.

• Documents and logs information on tracking systems and mainframe systems.

• Generates appropriate written correspondence to providers, members, and regulatory entities.

• Serves as subject matter expert for team and works on projects impacting development, interpretation, and implementation of medical policy or other managed care initiatives that may cross functional lines or states.

Minimum requirements:

• Requires MS in social work, RN or degree in a related behavioral health field and minimum of 5 years of experience in a managed care/healthcare setting; or any combination of education and experience, which would provide an equivalent background.

• Current active unrestricted license as a Licensed Clinical Social Worker, Marriage and Family Therapist, Clinical Psychologist, Licensed Professional Counselor or RN license to practice as a health care professional within scope of licensure in applicable state(s) or territory of the United States required.

Preferred skills, capabilities, and experiences:

• Utilization Management experience highly 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. A Fortune 20 company with a longstanding history in the healthcare industry, 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.

Elevance Health operates in a Hybrid Workforce Strategy, providing various levels of flexibility while also ensuring that associates have opportunities to connect in-person. Unless in a designated virtual-eligible role and specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles 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 2022, has been ranked for five years running as one of the 2023 World’s Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. 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.