Manager II Grievance / Appeals RN

Manager II Grievance / Appeals-RN

Location : Ohio-Cincinnati, Columbus, Mason, or Seven Hills (Must be within commutable distance to one of the listed locations.) Hybrid 1 : This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered. 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 an accommodation is granted as required by law.

The Manager II Grievance / 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 :

Preferred Skills, Capabilities and Experiences :

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.

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. 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.