Appeals and Grievance Analyst
December 10
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
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