Manager II - Grievances & Appeals - Provider Disputes at Elevance Health in Cerritos, California

Job Description:

Manager II - Grievances & Appeals - Provider Disputes




Location: This position will work a hybrid model (in office 1-2 days per week). The ideal candidate will live within 50 miles of one of our Open Access Pulse Points listed in this requisition.



The Manager II - Grievances & Appeals is 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.



How you will make an impact:

• 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 Experiences:

• Experience supervising a production-based preferred.
  
  


• Prior experience with healthcare insurance claims highly preferred
  
  


• Prior experience working with WGS claims system preferred.
  
  


• Strong communication skills (written and verbal) highly preferred.
  
  


• Strong analytical skills, understands and acts on root cause.
  
  

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.


For candidates working in person or remotely in the below locations, the salary* range for this specific position is $86,856 to $148,896


Locations: California,Colorado, Nevada, New York


In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.


* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law. Apply Now