Grievance & Appeals Case Analyst

Responsibilities

• Independently determines best resolution on assigned cases, incorporating clinical guidance from Partnership Medical Directors and Grievance & Appeal Nurse Specialists.
• Investigates member-disputes of denied benefits/services, collects new evidence, reassesses for coverage, executes final decisions, and communicates it to all stakeholders.
• Investigates member-reported concerns about dissatisfactory experiences while seeking care. Identifies facts, surveys the health care system, corrects root causes, and communicates outcomes to all stakeholders.
• Communicates with members throughout the investigation, offers customer-focused solutions, and practices exemplary customer service to all stakeholders.
• Frequent contact with internal departments, providers, third party administrators, and/or regulators.
• Manages assigned cases so they are completed within DHCS timeframes, according to G&A Desktop procedures, and/or as directed by management.
• Documents all casework activity thoroughly, accurately, timely, and ethically.
• Writes DHCS and NCQA compliant letters to members and providers.
• Provides leadership to the grievance support team to complete sub-components of the investigation process.
• Effective communicator in all modes of communication (e.g., written, verbal).

Qualifications

• Bachelor’s degree or four (4) years of related work experience, preferably in Grievances & Appeals, health care customer service, case management or health plan operations.
• Ability to solve problems, be a critical thinker and detail oriented. Familiar with managed care concepts, operations, policies and procedures, including but not limited to knowledge of grievance and appeal regulations.
• Strong knowledge of Microsoft Word, Excel, and Outlook.
• Ability to handle multiple tasks and meet deadlines. Strong organizational skills with ability to prioritize work.
• Must be able to work in a fast-paced environment, work well under pressure, and maintain professional composure when interacting with all stakeholders, including members.