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Medicare Grievance Analyst REMOTE

2 months ago

Charlotte, United States iMPact Business Group Full time

Our client is a nationally recognized not-for-profit health system, offering a full continuum of health services through their health plan, medical group, and hospital group.

Our client is looking for a Medicare Grievance Analyst.

100% Remote

Remote work for this position may be approved based on policy and business considerations. Some states are not eligible for remote work (CA, CT, MA, NJ, NY, Washington D.C.)


This is a 3 month contract with a potential of being extended for 6 additional months.

Equipment provided.


Responsibilities:

  • Responsible for the analysis, research and completion of complex member grievance investigations.
  • Effectively administer all steps of the member grievance.
  • Thoroughly investigate member grievances, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible.
  • Ensure compliance with all mandated, legislative, regulatory and accreditation requirements.
  • Assist members and staff throughout the process by providing complete information and follow up on a timely basis.
  • Ensure committee, State and Federal decisions are properly implemented.
  • Assist the Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements.
  • The Grievance Analyst makes decisions on moderately complex issues and work is performed without direction.
  • Exercises latitude in determining objectives and approaches to assignments.

Essential Functions:

  • Responsible for complex and thorough investigation of grievances: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the grievance captured (internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents).


  • Track all activity including communication for each grievance by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met.


  • Conducts root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course corrections.


  • Perform quality assurance reviews for case files, decision forms, documentation and logs to ensure they are complete, organized and secure and ensure all procedures are followed and time line requirements are met, including implementation of relevant Committees as needed.


  • Support with providing education and communicates training needs to Customer Service Leadership, when appropriate.


  • Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes and workflow.


  • Support in conducting root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course corrections


  • Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution Communicates, collaborates and acts as a consultant to internal and external customers in order to resolve complex issues.

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