Grievance​/Appeals Representative

Overview

Title: Grievance/Appeals Representative I

Locations: Woburn, MA and Manchester, NH

This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. 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 an accommodation is granted as required by law.

• Reviews, analyzes and processes member complaints in accordance with policies and claims events to determine the extent of the company's liability and entitlement.
• Conducts investigations and reviews of customer grievances and appeals involving provision of service and benefit coverage issues; communicates disposition of case to customers and 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 liability and/or provider's/beneficiary's 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 time frames established by regulatory/accreditation agencies or customer needs.
• Identifies barriers to customer satisfaction and recommends actions to address operational challenges.

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

• Good verbal and written communication, organizational, interpersonal skills and PC proficiency strongly preferred.

For candidates working in person or virtually in the location(s) below, the salary range for this position is $21.11/hr to $31.67/hr locations:
Massachusetts.

In addition to salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution. The salary offered is based on non-discriminatory factors and geographic location. Elevance Health is committed to equal pay for equal work regardless of gender, race, or any other category protected by law.

The salary range may be modified in the future and actual compensation may vary based on factors such as geographic location, work experience, education and skill level. Bonus, commission, benefits, or any other form of compensation remain at the company’s discretion unless required by policy, agreement or law.

Elevance Health operates in a Hybrid Workforce Strategy. Associates are required to work at an Elevance Health location at least once per week unless specified otherwise by the hiring manager. Specific onsite requirements will be discussed during the hiring process. Vaccination against COVID-19 and Influenza may be required for certain patient/member-facing roles as allowed by law.

Elevance Health is an Equal Employment Opportunity employer. Qualified applicants will be considered without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender identity or expression, marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status protected by law. Applicants requiring accommodation may contact elevancehealthj for assistance. Qualified applicants with arrest or conviction records will be considered in accordance with applicable laws.