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Grievance/Appeals Analyst II
2 months ago
Title: Grievance/Appeals Analyst II
Location:
This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The
Grievance/Appeals Analyst II
will be responsible for reviewing, analyzing and processing non-complex and some complex pre service and post service grievances and appeals requests in the Enterprise Grievance & Appeals Department from customer types (i.e. member, provider, regulatory, and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
How you will make an impact:
Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements.
As such, the analyst will strictly follow department guidelines and tools to conduct their reviews, and completion of the respective written communication documents to convey the determination.
The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.
Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses.
Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
Identify opportunities for improvement and any provide support and assistance to G&A Analyst I associates as needed.
Minimum Requirements
HS diploma or equivalent
Minimum of 1 year of Grievance & Appeals analyst experience
Minimum of 3 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background.
Preferred Qualifications
Associates degree preferred.
Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly preferred
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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