Anticipated End Date:

2024-09-13

Position Title:

Mgr II Grievance/Appeals (US)

Job Description:

Location: Open to any location but must meet the hybrid workplace model requirement.

Elevance Health supports a hybrid workplace model (virtual and office) with PulsePoint sites used for collaboration, community, and connection, with the minimum in-office commitment being 1-3 days in an office per week.

Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

Responsible for 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.

PRIMARY DUTIES:

• 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.

Minimum Requirements: 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; or any combination of education and experience which would provide an equivalent background.

 

Preferred Skills, Capabilities and Experience:

• Advanced knowledge of ETL data processing using query language such as SQL or Power Query.
• Expertise in analyzing large datasets.

 

 

Job Level:

Manager

Workshift:

1st Shift (United States of America)

Job Family:

CLM > Claims Support

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

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.

How We Work

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.

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. Unless 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 an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

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 [email protected] for assistance.