Anticipated End Date:
2026-11-28
Position Title:
SCA Appeals Representative Sr.
Job Description:
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
Job Level:
Non-Management Non-Exempt
Workshift:
1st Shift (United States of America)
Job Family:
SCA >…