Appeals and Grievance Analyst

Appeals And Grievance AnalystUnder the general direction of the Member Appeals and Grievance Supervisor the Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual works collaboratively with the member and/or the member's authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member's appeal or grievance providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. The employee must have the ability to learn and apply Point32Health's policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for all lines of business.Job DescriptionAct as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member's appeal or grievance is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state or federal specific regulations that apply.Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirementsManage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customersConsult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.Make recommendations on appeal decisions based on the member's benefits and individual circumstances presented.Perform other duties and projects as assigned.Qualifications What You Need To Perform The JobCertification and LicensureEducationRequired (minimum): Associate's Degree or equivalent experience in health care, conflict resolution or related fieldPreferred: Bachelors Degree in related fieldExperienceRequired (minimum): 2-4 years' experience as a customer service or member services representative in health care or insurancePreferred: 2 years' Appeals and Grievance experienceSkill RequirementsHealth care benefit and regulatory knowledge preferred.Knowledge of insurance products, policies and procedures preferred.Demonstrated proficiency in operating a computer and related equipment including knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.Must possess initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize one's own work to assure maximum efficiency and compliance.Must be able to organize, plan and implement the functions of Member Appeals and Grievances, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws.Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner. Requires strong verbal and written skills to effectively communicate at both detail and summary levels to a variety of constituents.Requires excellent interpersonal skills to communicate and work with multiple constituents.Requires ability to understand and be compliant with State and Federal regulations.Superior investigation, analytical and problem-solving skills.Excellent customer service and interpersonal skills.Ability to work independently and collaborate as part of a team.Working Conditions and Additional RequirementsMust be able to work under normal office conditions and work from home as required.Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.May be required to work additional hours beyond standard work schedule.Weekend Coverage may be required on a rotating basis as regulated for line of business.May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.Salary Range$22.92 -$34.38Compensation & Total Rewards OverviewThe annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:Medical, dental and vision coverageRetirement plansPaid time offEmployer-paid life and disability insurance with additional buy-up coverage optionsTuition programWell-being benefitsFull suite of benefits to support career development, individual & family health, and financial healthWe Welcome AllAll applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.Scam AlertPoint32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org