Grievance and Appeals Analyst I

Position Summary

The Grievance and Appeals Analyst I is responsible for the review, investigation, and resolution of member grievances and appeals within a managed-care health plan. Ensures all activities are conducted in compliance with regulatory requirements, including those established by the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). Supports timely, accurate, and compliant resolution of member and provider complaints while maintaining a high standard of customer service and operational excellence.

Essential Duties And Responsibilities

• Conducts comprehensive review, investigation, and resolution of member grievances, appeals, and complaints in accordance with CMS, NCQA, and state regulatory guidelines.
• Researches and analyzes claims, benefit plans, authorizations, and supporting documentation to determine appropriate outcomes.
• Ensures all cases are processed within mandated regulatory and internal timelines.
• Requests, reviews, and interprets medical records, provider documentation, and itemized bills as needed to support case determinations.
• Applies contract language, benefit structures, medical policies, and coverage guidelines to grievance and appeals decisions.
• Collaborates with internal departments (e.g., Medical Management, Provider Relations, Compliance) to ensure accurate and consistent resolutions.
• Identifies root causes of issues, including claims processing errors, system configuration discrepancies, or Provider billing concerns.
• Prepares clear, concise, and compliant written correspondence to members, providers, and authorized representatives outlining determinations.
• Documents all case activity, findings, and outcomes in accordance with audit and regulatory requirements.
• Tracks and reports trends in grievances and appeals to support quality improvement initiatives.
• Communicates with members and providers via written and verbal channels to obtain additional information or clarify case details.
• Mets or exceeds departmental productivity and quality performance standards.

Qualifications And Education

• Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing; or equivalent combination of education and experience.
• Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances.
• Understanding of NCQA standards related to member complaint and appeals processes.
• Experience reviewing claims, including eligibility, coordination of benefits (COB), and denial management.
• Strong analytical and problem-solving skills with attention to detail.
• Excellent written and verbal communication skills, with the ability to compose regulatory-compliant correspondence.
• Strong organizational and time management skills with the ability to manage multiple priorities and meet strict deadlines.
• Proficiency in Microsoft Office applications and relevant claims or case management systems.

Preferred Qualifications

• Experience working in a managed care organization supporting Medicaid, Medicare Advantage, or Marketplace plans.
• Familiarity with medical terminology, coding, and utilization management processes.
• Prior experience handling complex or escalated grievance and appeals cases.
• Background in a healthcare setting such as a hospital, provider office, or health plan operations.