Appeals and Grievance Analyst

December 10, 2024

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Point32Health

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Point32Health is a leading nonprofit health and well-being organization that provides health coverage and services for individuals at all life stages. Through its family of companies, including Harvard Pilgrim Health Care and Tufts Health Plan, Point32Health offers a variety of health plans, programs, and services encompassing medical, pharmacy, wellness, and behavioral health. Point32Health is committed to health equity and has been recognized for its inclusive practices, earning distinctions in areas such as health equity, disability inclusion, and LGBTQ+ workplace inclusion. With a focus on innovative solutions and high-quality coverage, Point32Health strives to create a better healthcare experience for its members and communities.

Healthcare

1001 - 5000 employees

⚕️ Healthcare Insurance

🤝 Non-profit

🧘 Wellness

📋 Description

• Act 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 compliant final disposition. • Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements. • Manage the collection of documents and records needed to fully research the appeal or complaint request. • Consult 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.

🎯 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 • Initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize one’s own work • Ability to organize, plan and implement the functions of Member Appeals and Grievances, maintain timelines and turnaround times • Demonstrated ability to synthesize and process complex information and deliver the information clearly, concisely, and articulately • Strong verbal and written skills • Excellent interpersonal skills • Ability to understand and comply 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 ability to communicate this information clearly and concisely

🏖️ 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