Appeals and Grievance Analyst

HealthEdge•Remote,

1d•$20 - $25•Remote

About The Position

The Appeals and Grievance Analyst, acting in a quality assurance capacity, is responsible for the processing Appeals and Grievances by evaluating the organization's initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case. All Appeals and Grievance cases must be documented in the highest quality possible, ensuring the Appeals and Grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations.

Requirements

Bachelor’s degree in Business Administration, Economics, Health Care, Information Systems, Statistics or other related field is required.
Five years experience in a grievance and appeals environment including experience with the grievance and appeals regulations per CMS.
Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans.
Experience working in or with Medicare Advantage plans, or Independent Review Entities.
Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes.
Knowledge in claims, authorizations, and Medicare Advantage plans.
Proven problem-solving skills and ability to translate knowledge to corporate departments.
Strong communication skills are required to understand, interpret, and communicate ideas.
Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc).
Working knowledge of data languages such as SAS or SQL.
Strong analytical, organizational, planning and problem solving skills.
Ability to effectively interface with employees at all levels.
Understand and apply statistical inference.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write reports and correspondence.
Ability to speak effectively before groups of customers or employees of organization.
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
Demonstrated track record of generating results and having an impact on organizations.
Strong focus and drive to serve the customer.
Ability to work in a high paced environment.
Ability to consistently exceed deadlines.

Nice To Haves

Master’s Degree in related field preferred.
Certification or progress toward certification is highly preferred and encouraged.
Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred.

Responsibilities

Investigate and thoroughly document findings on all grievances and appeals.
Prepare Appeal case recommendations for initial review process.
Coordinate appropriate reviewer assignment for Appeals and Grievance cases.
Responsible to move Appeals and Grievances through each review level to ensure timely completion.
Bring to management’s attention any system or process issues determined during the investigation of the appeal or grievance.
Coordinate effectively with the Information technology department on upgrades/fixes/changes
Participate in the departmental audit/oversight program that focuses on continuous quality improvement.
Participate in compliance committees to help continuously improve initial decision making.