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Appeals and Grievance Analyst
Appeals and Grievance Analyst
Remote Worker - N/A • Appeals Grievances
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 analyst 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.
Major Work Activities
Ensures timely review, research, and resolution of appeals, grievances, and complaints within guidelines. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy. Detailed documentation of all research and findings in case files and corresponding trackers with no grammatical errors for easy and accurate retrieval. Make and receive inbound and outbound calls as needed to members, providers, etc. using the call tracking platform.
Consult, collaborate and communicate with medical directors and various departments (i.e. Member Services, Care Management, Claims, Appeals Review Committee), as well as external entities (i.e. Providers and Vendors) to collect initial and subsequent information as needed. Works independently to complete tasks.
Initiate claim adjustments, provider education, etc. when necessary and follow and track until completion.
Log and track grievances, appeals, and other types of complaints as needed. Prepares and generates complaint case files and mails letters, forms, and other complaint-related notices. Analyze, track and trend patterns and areas of concern to management.
Other duties as assigned.
High School Diploma or equivalent
One (1) or more years of health plan experience
Proficient in Word, Excel, and PowerPoint
Annual Flu Vaccine
Knowledge, Skills, and Abilities
Customer service experience in a managed care setting
Strong in the following competencies:
Communication, written and oral
Ability to work independently
Availability to work after normal business hours including weekends and holidays
One (1) or more years of Medicare Part C & 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
Preferred Knowledge, Skills, and Abilities
Preferred prior appeals and grievance related work
Screener Questions: Care N Care Insurance Screeners
Do you now, or will you in the future, require sponsorship for employment visa status in the United States to work legally for Care N' Care Insurance Company of North Carolina, Inc. d/b/a HealthTeam Advantage? (required) (auto reject if incorrect)
Are you at least 18 years of age? (required) (auto reject if incorrect)
If presented with an offer would you be willing to complete a background check? (required) (auto reject if incorrect)
Do you have Medicare Advantage experience? (required)
Are you legally authorized to work in the United States for Care N' Care Insurance Company of North Carolina, Inc. d/b/a HealthTeam Advantage? (required) (auto reject if incorrect)
It is the policy of Care N' Care Insurance Company of North Carolina, Inc. that all employees be vaccinated, with certain exceptions for religious or medical accommodations under the Americans with Disability Act. Are you able to comply with this policy if offered employment? (required) (auto reject if incorrect)
Time: Full time
Updated: 8/30/2021 11:01:51 AM