SCA Appeals Representative Sr.

SCA Appeals Representative Sr.

Virtual: 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.

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.

Wellpoint Federal, a subsidiary of Elevance Health, brings deep industry expertise and healthcare service capabilities to support federal programs. The organization delivers solutions across claims administration, data, and care delivery to help address complex challenges and improve health outcomes for federal populations.

The SCA Appeals Representative Sr. is responsible for investigating and reviewing customer appeals regarding provision of service and benefit coverage issues.

How you will make an impact

Job duties include, but are not limited to:

• Triages clinical and non-clinical inquiries as well as 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.

• Responds to oral and written complaints.

• Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.

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

• Generates written correspondence to customers such as members, providers and regulatory agencies. Identifies barriers to customer satisfaction and recommends actions to address operational challenges.

• Pursues ongoing education/training on benefits/services to ensure accurate resolution of grievances and appeals, and overall industry knowledge and development (i.e. HIAA, LOMA, etc.). Documents and logs inquiry/appeal/grievance information in tracking system.

• Under minimal supervision, resolves inquiries as well as grievances and appeals requests from all customer and product types related to non-clinical services and quality of service issues.

• Handles more complex customer issues requiring adaptation of responses or extensive research.

• Makes administrative exceptions within prescribed guidelines.

• Investigates, summarizes, and makes recommendations for non-clinical cases.

• Actively seeks, evaluates and understands information needed to make effective decisions.

• Assists other grievance and appeals staff on file decisions.

• Provides direction and guidance to other team members.

• Provides leadership and fosters a supportive environment.

• Performs other related duties as required.

Minimum Requirements:

• Requires high school diploma or equivalent and a minimum 4 years related experience working in grievances and appeals; 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 to meet the residency requirement of living in the United States for at least three of the past five years.

Preferred Skills, Capabilities and Experiences:

• Understanding of the application of benefits contracts, pricing, policies and legislative regulations, verbal and written communication skills, organizational skills, interpersonal skills, PC proficiency strongly preferred.

• Appeals knowledge is heavy preferred

• Knowledge of Part A and B Medicare is 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.

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 should submit the Accessibility Accommodation Request Form (https://forms.cloud.microsoft/pages/responsepage.aspx?id=8giMvgesLESaRuvu61vU17EJaA0EP3FIissI8zmZ\_NpUNUgyTFRUMkY5NE5JNDFWMkhaUzQxMkJLWS4u&route=shorturl) and a member of the team will be in contact.

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 (https://info.flclearinghouse.com/) .