Appeals and Grievance Analyst
Point32Health
full-time
Posted on:
Location Type: Remote
Location: Remote • District of Columbia, Florida, Maine, Massachusetts, New Hampshire • 🇺🇸 United States
Visit company websiteSalary
💰 $23 - $34 per hour
Job Level
JuniorMid-Level
About the role
- 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 the final disposition of a member’s appeal or grievance is compliant with the regulatory requirements set-forth by NCQA (National Committee for Quality Assurance), DOI (Dept of Insurance), CMS, DOL and any state or federal specific regulations that apply.
- 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 (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customers
- 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.
- Perform other duties and projects as assigned.
Requirements
- Associate’s Degree or equivalent experience in health care, conflict resolution or related field
- 2-4 years' experience as a customer service or member services representative in health care or insurance
- 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.
- 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
health care knowledgeconflict resolutioninsurance products knowledgeregulatory compliancedocument collectioncase managementanalytical skillsproblem-solving skillscustomer serviceWindows applications proficiency
Soft skills
communication skillsinterpersonal skillsinitiativejudgmentobjectivityorganizational skillsplanning skillsindependencecollaborationsynthesis of complex information
Certifications
Associate’s Degree