SCA Appeals Representative I

SCA Appeals Representative I Location :  This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. *Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. . Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations. The SCA Appeals Rep I is Responsible for reviewing, analyzing, and processing non-complex pre and post service grievances and appeals requests from customer types (i.e., member, provider, regulatory, and third party) and multiple products (Part A & B) which are related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances. How you will make an impact: Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements as well as internal policies and claims events requiring written responses. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize.  Routes summaries and information to nursing and/or medical staff for review.  Strictly follows department guidelines and tools to conduct reviews.   Serves as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Requires a High school diploma or GED and a minimum of 1 year experience working in grievances and appeals, claims, or customer service; or any combination of education and/or experience which would provide an equivalent background.  This position is part of our Wellpoint Federal division which, per CMS TDL 190275, requires foreign national applicants meet the residency requirement of living in the United States at least three of the past five years. Preferred Experience, Skills, and Capabilities: Familiarity with medical coding and medical terminology demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, all of the company's internal business processes, and internal local technology strongly preferred. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: SCA > SCA Wage Determination 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.

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