Grievance/Appeals Representative II at Elevance Health in San Antonio, Texas

Job Description:

Be Part of an Extraordinary Team



BioPlus Specialty Pharmacy is now part of CarelonRx (formerly IngenioRx), and a proud member of the Elevance Health family of companies. Together, CarelonRx and BioPlus offer consumers and providers an unparalleled level of service that's easy and focused on whole health. Through our distinct clinical expertise, digital capabilities, and broad access to specialty medications across a wide range of conditions, we deliver an elevated experience, affordability, and personalized support throughout the consumer's treatment journey.



Title: Grievance/Appeals Representative II



Location: Onsite at TX-SAN ANTONIO, 4751 HAMILTON WOLF RD, STE 101


Candidates must reside within 50 miles or 1-hour commute each way of the relevant Elevance Health location.



Build the Possibilities. Make an extraordinary impact.



The Grievance/Appeals Representative II is responsible for reviewing, analyzing and processing policies related to claims events to determine the extent of the company's liability and entitlement.



How you will make an impact:



Primary duties may include, but are not limited to:

• Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
  
  


• Contacts customers to gather information and communicate disposition of case; documents interactions.
  
  


• Generates written correspondence to customers such as members, providers and regulatory agencies.
  
  


• Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
  
  


• May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
  
  


• Prepares files for internal or external review by analysts, medical staff or outside consultant.
  
  


• Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
  
  


• Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
  
  

Minimum Requirements:

• Requires a HS diploma or equivalent and a minimum of 2 years' experience in customer service, preferably in a managed care environment, medical office, or health insurance; or any combination of education and experience which would provide an equivalent background.
  
  

Preferred Skills, Capabilities and Experiences:

• Certified Pharmacy Technician (CPhT) or related certification strongly preferred.
  
  


• Minimum of 2 years of experience in healthcare or pharmacy services, with specific experience with pharmacy adjudication, prior authorizations, and appeals preferred.
  
  


• Capacity to work autonomously as well as collaboratively within a team preferred.
  
  


• Strong understanding of specialty medications and the pharmaceutical landscape preferred.
  
  


• Excellent communication, organizational, and problem-solving skills preferred.
  
  


• Familiarity with healthcare regulations and compliance, especially related to the 340B program preferred.
  
  


• Proficient with healthcare software and technology used for managing prior authorizations preferred.
  
  

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.

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. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

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. Apply Now