Job ID: JP00044336

Anticipated Start Date: 4/1/24

Please note this is the target date and is subject to change. BCforward will send official notice ahead of a confirmed start date.

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 contract workers (via BCforward) 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?

An entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex preservice and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

Primary duties may include, but are not limited to:

• Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language.
• 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 and route to nursing and/or medical staff for review.
• The grievance and appeal work are subject to applicable accreditation and regulatory standards and requirements.
• The analyst will strictly follow department guidelines and tools to conduct their reviews.
• Responsible for reviewing components of the URAC and NCQA accreditations are 'must pass' items to achieve the accreditation.
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
• Supports the Payment Dispute process across CSBD business.
• Specifically responsible for the resolution of Provider Payment Appeal requests.
• Reviews and analyzes provider requests to investigate the outcome of a Reconsideration.
• Considers all information when determining whether to uphold or overturn primary decision.
• Works with various departments including Provider Solutions and Health Plan Operations leadership, when necessary, to determine root cause and appropriate resolution.
• Must work with Claims Operations to remediate impacted claims.

Requirements:

• Requires a High school diploma or GED.
• 3 to 5 years' experience working in grievances and appeals, claims, or customer service, familiarity with medical coding and medical terminology.
• Demonstrates business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology; or any combination of education and/or experience which would provide an equivalent background.

Preferred:

• WGS Claims Adjustment
• WGS Inquiry/PDR Experience

Job Type: Contract to hire.

Additional Details:

• 100% Remote
• Hours will be flexible to accommodate either (EST) or (PST) business hours.

About BCforward:

Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world. Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward’s 6,000 consultants support more than 225 clients globally.

BCforward champions the power of human potential to help companies transform, accelerate, and scale. Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years. Our strong culture and clear values have enabled BCforward to become a market leader and best in class place to work.

BCforward is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against based on disability.

To learn more about how BCforward collects and uses personal information as part of the recruiting process, view our Privacy Notice and CCPA Addendum. As part of the recruitment process, we may ask for you to disclose and provide us with various categories of personal information, including identifiers, professional information, commercial information, education information, and other related information. BCforward will only use this information to complete the recruitment process.

This posting is not an offer of employment. All applicants applying for positions in the United States must be legally authorized to work in the United States. The submission of intentionally false or fraudulent information in response to this posting may render the applicant ineligible for the position. Any subsequent offer of employment will be considered employment at-will regardless of the anticipated assignment duration.