Appeals and Grievance Analyst

About the role

The Appeals and Grievance Analyst plays a critical role in the quality assurance of health plan operations. This position is responsible for investigating and documenting grievances and appeals, preparing recommendations, and ensuring timely and accurate processing according to CMS guidelines.

Responsibilities

• Investigate and thoroughly document findings on all grievances and appeals.
• Prepare Appeal case recommendations for initial review process.
• Cook up appropriate reviewer assignments for Appeals and Grievance cases.
• Maintain the flow of Appeals and Grievances through each review level to ensure timely completion.
• Inform management about any system or process issues identified during the investigation.
• Collaborate with IT department on upgrades/fixes/changes.
• Participate in departmental audit/oversight programs for continuous quality improvement.
• Contribute to compliance committees to enhance initial decision-making processes.

Requirements

• Bachelor’s degree in Business Administration, Economics, Health Care, Information Systems, Statistics, or a related field is required.
• Master’s Degree in related field preferred.
• Certification or progress toward certification in grievance and appeals is highly preferred and encouraged.
• Five years experience in a grievance and appeals environment, including experience with CMS regulations.
• 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.

Qualifications

• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.
• Work across multiple time zones in a hybrid or remote work environment.
• Long periods of time sitting and/or standing in front of a computer using video technology.

Skills

• 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.

Benefits

UST HealthProof offers a comprehensive benefits package designed to support you and your family. Details will be provided upon offer acceptance.

Pay

The annual US base salary range for this position is $20 - $25/hr. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.

Schedule

This position is available on a full-time, permanent basis and is exempt under FLSA classification. The role is currently remote, with a US-based geographic responsibility.