Appeals Analyst

Appeals Analyst

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Our client provides a range of health solutions for patients in rural communities. With new projects on the horizon, they are hiring a Appeals Analyst to aid in the development and coordination of all written documentation and correspondence to the member outlining final disposition of the member’s appeal or grievance providing further appeal options as appropriate.

The Appeals Analyst will oversee the 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 and any state or federal specific regulations that apply.

This Role Offers:

Competitive base salary plus comprehensive benefits, including medical/dental/vision, 401(K), and more. Stable company with over seven decades of experience. Tight-knit culture focused on taking care of their employees. Ample opportunities for growth and career advancement. High employee tenure with low red tape culture. They hire professionals and trust their expertise, giving them room to make tangible impacts.

Focus:

Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.

Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Skill Set:

Associates degree in a related field. 3+ years of experience with health care benefits. Demonstrated business writing proficiency, understanding of provider networks, the medical management process, and claims processes. Understanding of classification, processing, and resolution of grievances. Strong interpersonal skills with the ability to build lasting and meaningful relationships with all levels of departments.

Ability to make critical decisions regarding research and investigation to appropriately resolve all grievances. Strong MS Office and CRM management skills. Strong project management, problem solving, and time management skills and extremely detail orientated. Background in a fast-paced environment with proven ability to work well under pressure.