Grievance And Appeals Analyst

JOB SUMMARY

The job conducts and documents thorough investigations of all complaint and grievance case types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, processes and enrollment rules. Responsible for all aspects of nonclinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to clinical appeals, facilitating member verbal and written notification and correct authorization of services. CTM complaints, investigation and response to executive and legislative inquiries also performed by the Appeal Analyst.

ESSENTIAL RESPONSIBILITIES

• Complete and document thorough investigation of all grievances and appeals. Perform research and evaluate output requirements and formats. Request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Effective and compliant effecutation of appeals. Communicate business operational requirements to internal groups responsible for compliant handling.
• Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff. Compose and complete oral and written responses to all parties. Communicate effectively with colleagues, successfully articulating issues, problems and solutions. Assist in functional walk throughs. May require additional support from more experienced team members.
• Recommend process efficiencies, strategies for improvement and/or solutions to align with business strategies. Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of process solutions, implementing strategies and control measures, influencing organizational change related to business processes.
• Participate in process improvement meetings and/or discussions, recommending process process efficiencies and/or strategies fro improvement.
• Ensure quality assurance of appeal/grievance work, assist in development of desktop procedures and/or training materials.
• Other duties as assigned

EDUCATION

Required

• High School Diploma/GED

Substitutions

• None

Preferred

• None

EXPERIENCE

Required

• 3 - 5 years in Appeals or Customer Service

Preferred

• None

LICENSES AND CERTIFICATIONS

Required

• None

Preferred

• None

SKILLS

• Customer Service
• Communication Skills
• CMS Regulations
• Claims Processing

Language (Other than English)

None

Travel Required

0% - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, age, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, age, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.

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