Appeals and Grievance Analyst

5 days ago

🍂 Massachusetts – Remote

Although this job is listed in Massachusetts, this company may be open to hiring remote in other states.

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Point32Health

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Point32Health is a leading nonprofit health and well-being organization dedicated to delivering a better health care experience to the communities it serves. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a range of health plans, programs, and services aimed at guiding and empowering individuals and families towards healthier lives. The organization emphasizes innovation, quality, and health equity, striving to provide access to high-quality health care for everyone, regardless of their circumstances or life stages.

Healthcare

1001 - 5000 employees

Founded 2021

⚕️ Healthcare Insurance

🤝 Non-profit

🧘 Wellness

📋 Description

• Under the general direction of the Member Appeals and Grievance Supervisor the Member 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.

🎯 Requirements

• Associates Degree or equivalent experience in health care, conflict resolution or related field • 3-5 years health care or insurance experience • Health 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 in order 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 • Working knowledge of plan products and benefits and the ability to communicate this information to members, providers, employers and external agencies clearly and concisely. • Ability to work independently and collaborate as part of a team

🏖️ Benefits

• Medical, dental and vision coverage • Retirement plans • Paid time off • Employer-paid life and disability insurance with additional buy-up coverage options • Tuition program • Well-being benefits • Full suite of benefits to support career development, individual & family health, and financial health