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Appeals and Grievances Analyst

Job Summary
The Appeals and Grievance Analyst performs research, investigation and analysis of appeals, grievances, and other types of complaints filed by members and customers to administer timely resolution within state and federal guidelines, benefit plan guidelines, and company policies and procedures. The incumbent is expected to maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with any type of complaint and to make no disclosures of such information except to persons authorized to receive it in the conduct of business.

Qualifications

Required Education
High School Diploma or GED

Preferred Education
Associate's Degree

Required Experience
One (1) or more years of Medicare Advantage Part C experience
Proficient in Word, Excel and PowerPoint

Preferred Experience
One (1) or more years of Medicare Part D experience
Medicare Advantage Appeals and Grievance experience
Experience working with regulatory agencies and in a compliance environment
Experience interacting with other healthcare professionals and proficiency in medical and pharmacy terminology

Major Work Activities
Logs and tracks verbal or written member grievances and appeals and other types of complaints
Conducts research into complaints and collaborates, coordinates, and communicates with various departments (i.e. Member Services, Care Management, Claims), as well as external entities (i.e. Providers and Vendors) to collect initial and additional information as necessary. Works independently to complete tasks.
Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy. Maintains all complaint case files to assure easy and accurate retrieval of all related documents.
Prepares and generates complaint case files and mails letters, forms, and other complaint related notices
Analyze, track and trend patterns and areas of concerns related to member complaints
Other duties as assigned

Knowledge, Skills and Abilities
Customer service experience in managed care setting
Strong in the following competencies:
Decision making/Judgment
Problem solving/Analysis
Communication, written and oral
Organizational Skills
Time Management
Preferred prior appeals and grievance related work
Ability to work independently
Availability to work after normal business hours including weekends and holidays

Time:  Full time
Salary:  Salary
Category:  Clinical/pharmacy/quality

Updated: 10/16/2018 1:59:53 PM