SCA Appeals Representative I

Quick Facts

Hybrid/virtual role with occasional required in-person training. Candidates must be within commuting distance of the posting location(s) unless accommodation is granted as required by law.

Description

The SCA Appeals Representative I reviews, analyzes, and processes non-complex pre- and post-service grievances and appeals requests across multiple customer types (members, providers, regulatory, and third parties) and products (Part A & B), covering both clinical and non-clinical services and quality-related issues.

Responsibilities

• Review, analyze, and process non-complex grievances and appeals in accordance with external accreditation and regulatory requirements and internal policies.
• Use guidelines and review tools to research and analyze issues, along with relevant claims and medical records, to support approvals or written summaries.
• Route summaries and information to nursing and/or medical staff for review.
• Follow department guidelines and tools for all reviews.
• Serve as a liaison between grievances & appeals and internal groups such as medical management, legal, and service operations.

Requirements

• High school diploma or GED
• Minimum 1 year experience in grievances and appeals, claims, or customer service (or equivalent education/experience)
• If applicable, foreign national applicants must meet the CMS residency requirement: live in the United States at least three of the past five years

Benefits

• Merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement)
• Medical, dental, and vision insurance
• Short- and long-term disability benefits
• 401(k) with match and stock purchase plan
• Life insurance, wellness programs, and financial education resources