Appeals and Grievance Analyst

November 6

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Point32Health

WebsiteLinkedInAll Job Openings

Healthcare

1001 - 5000

Description

• Responsible for managing and coordinating member appeals and grievance cases according to regulations • Act as a member advocate, communicating the appeal and grievance process clearly • Manage assigned cases from documentation, investigation, to resolution • Review and interpret product and benefit designs according to regulations • Collect documents needed to research appeals or complaints • Consult with subject matter experts as necessary • Make recommendations on appeal decisions based on benefits and individual circumstances

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 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