Appeals and Grievance Analyst

Point32Health

1d • $23 - $34

About The Position

Under the general direction of the Member Appeals and Grievance Supervisor the Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual works collaboratively with the member and/or the member’s authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member’s appeal or grievance providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. The employee must have the ability to learn and apply Point32Health’s policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for all lines of business.

Requirements

• Health care benefit and regulatory knowledge preferred.
• Knowledge of insurance products, policies and procedures preferred.
• Demonstrated proficiency in operating a computer and related equipment including knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.
• Must possess initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize one’s own work to assure maximum efficiency and compliance.
• Must be able to organize, plan and implement the functions of Member Appeals and Grievances, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws.
• Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner.
• Requires strong verbal and written skills to effectively communicate at both detail and summary levels to a variety of constituents.
• Requires excellent interpersonal skills to communicate and work with multiple constituents.
• Requires ability to understand and be compliant with State and Federal regulations.
• Superior investigation, analytical and problem-solving skills.
• Excellent customer service and interpersonal skills.
• Ability to work independently and collaborate as part of a team.

Nice To Haves

• 2-4 years' experience as a customer service or member services representative in health care or insurance
• 2 years’ Appeals and Grievance experience

Responsibilities

• Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member’s appeal or grievance is compliant with the regulatory requirements set-forth by NCQA (National Committee for Quality Assurance), DOI (Dept of Insurance), CMS, DOL and any state or federal specific regulations that apply.
• Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements
• Manage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customers
• Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
• Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
• Perform other duties and projects as assigned.

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees