Member Appeals & Grievance Analyst-2

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, you'll bring strong analytical skills, attention to detail, and a customer-focused approach. Knowledge of Medicare and CMS regulations, as well as experience with the appeals and grievance process, is essential. A clinical background or prior experience in a healthcare setting is preferred. You should also demonstrate strong data entry accuracy, case management skills, and experience using or enthusiasm for leveraging AI tools (e.g., Copilot) to improve workflow efficiency.

This is a fully remote role with a 40-hour work week, including required weekend coverage every weekend. An agreement to remain in the weekend role for a minimum of 2 years after completion of all training is required.

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 service to members, providers, and CMS.
• Maintaining knowledge of and adhering to CMS regulations and guidelines affecting the appeal/grievance/complaint process.

Requirements

• Associate’s degree or equivalent work experience.
• 2 years of customer service and/or claims experience.

Skills

• Proficient in Microsoft Office (Outlook, Word, Excel, and PowerPoint).
• Strong oral and written communication skills.
• Strong 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, and documents pertinent to case reviews.
• Knowledge of CMS regulations and guidelines related to appeals, grievances, and complaints.

Schedule

• 40-hour work week, fully remote.
• Required weekend coverage every weekend.
• Minimum 2-year commitment to the weekend role after completion of training.