Member Appeals & Grievance Analyst-2

BlueCross BlueShield of Tennessee • Chattanooga, TN

1d • Remote

About The Position

In this role, you will review and process appeals and grievances submitted by members and providers, ensuring timely and accurate resolution in compliance with CMS and Medicare guidelines. You will evaluate cases, determine appropriate next steps, and manage multiple priorities while meeting required turnaround times. You’ll play a critical role in maintaining regulatory compliance, improving member experience, and supporting high-quality outcomes through detailed case analysis and effective use of digital tools to drive efficiency. To be successful in this role, in addition to the core job requirements, you'll bring strong analytical skills, attention to detail, and a customer-focused approach. You will be a strong candidate if you have knowledge of Medicare and CMS regulations, as well as experience with the appeals and grievance process. A clinical background or prior experience in a healthcare setting (preferred) will further strengthen your candidacy. Additionally, you should demonstrate strong data entry accuracy and case management skills, along with experience using or enthusiasm for leveraging AI tools (e.g., Copilot) to improve workflow efficiency. We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.

Requirements

• Associates degree or equivalent work experience required
• 2 years - Customer service and/or claims experience
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Proficient oral and written communication skills
• Proficient interpersonal and organizational skills
• Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment
• Capacity to solve problems and manage multiple assignments with critical deadlines; including analyzing claims, medical records & documents pertinent to the case review
• Knowledge of CMS regulations and guidelines related to appeals, grievances and complaints

Nice To Haves

• A clinical background or prior experience in a healthcare setting
• Experience using or enthusiasm for leveraging AI tools (e.g., Copilot) to improve workflow efficiency.

Responsibilities

• Documenting and investigating the substance of the appeal, grievance, or complaint and the action taken, including any aspects of clinical care or reimbursement issues involved.
• Notifying involved parties of the outcome of a review (i.e. approval and/or denial of an appeal, grievance or complaint), including CMS and the member or appellant of the resolution of all CMS complaints in the appropriate timeframes as set forth by the applicable regulatory rules and regulations.
• Providing excellent customer services to members, provider and CMS.
• Maintaining knowledge of and adhering to CMS regulations and guidelines affecting the appeal/grievance/complaint process.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree