What are the responsibilities and job description for the SCA Appeals Representative I position at Elevance Health?
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.
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
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.
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 and Influenza. 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 elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.
- 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. .
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.
- 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.
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.
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 and Influenza. 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 elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.