Appeals Analyst- GP

About the role

The incumbent manages end‑to‑end complaint and appeal cases, conducting thorough investigations, ensuring regulatory and policy compliance, and documenting clear, defensible decisions. The role coordinates with internal and external stakeholders to deliver timely, accurate resolutions, partners with State agencies and Departments of Banking and Insurance as needed and supports Medicaid and Medicare compliance including awareness of impacts to Medicare STARS performance. The Analyst prepares comprehensive case files for review by leadership, CMS/State entities, and Administrative Law Judges, maintains detailed tracking and documentation, and analyzes trends to drive quality improvement and enhance the member experience.

Responsibilities

• Prepare comprehensive appeal files and present cases to the Leadership Appeals Workgroup.
• Coordinate submission to independent external reviewers (IRE) and Administrative Law Judge (ALJ) as needed, ensuring exhibits include claim records, authorizations, research summary, evidence of coverage, timelines, and documentation are complete, accurate, and well‑organized.
• Provides clear, comprehensive explanations of denial decisions, benefit coverage, and case handling.
• Investigate and analyze member/provider complaints and appeals by gathering documentation, interviewing stakeholders, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claim history to validate accuracy, ensure proper configuration and adjudication, and confirm case completeness and compliance with all regulatory, contractual, and organizational requirements.
• Apply critical thinking to determine root cause, validate findings, and recommend appropriate resolutions or corrective actions, while drafting clear, accurate written determinations and correspondence within required turnaround times to ensure messaging is professional and customer‑friendly.
• Prepare comprehensive appeal files to be presented to the Leadership Appeals Workgroup and for submission to independent external reviewers (IRE), ensuring files include all relevant documentation, claim charts, medical records, Evidence of Coverage, and other Plan documents.
• Search and review