Appeals And Grievances Analyst

Contract to Hire

Our client is a well known Health care provider in Tennessee with GREAT benefits.

• Child care support
• And MORE
• 401k
• Pension Plan for Full-Time employees

Under the general direction of the Appeals and Grievance Manager, the Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member and provider appeals and grievance received by our Client. This individual works collaboratively with the member/provider and/or the member’s authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. Responsibilities include development and coordination of all written documentation and correspondence to the member/provider outlining final disposition of the member’s or provider’s appeal or grievance providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. The employee must have the ability to learn and apply our client's policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination, efficient administration and resolution of member and provider appeals and member grievances submitted by our Client's members and providers for the Medicare Advantage product.

GENERAL RESPONSIBILITIES

• Act as a member/provider advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.

• Manage assigned 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.

• Review and interpret product and benefit designs according to State and Federal regulatory requirements

• Manage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or grievance (as appropriate) request with both internal and external customers.

QUALIFICATIONS

Education: Associates Degree or equivalent experience in health care, conflict resolution or related field.

Work Experience:

• 3-5 years health care or insurance experience

• Health care benefit and regulatory knowledge preferred

• Knowledge of insurance products, policies and procedures preferred.

Skills/ Competencies:

• 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 for 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 in order 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

• Working knowledge of plan products and benefits and the ability to communicate this information to members and providers.

• Ability to work independently and collaborate as part of a team

• Must be able to work under normal office conditions and in a remote capacity from home as required.

• Work requires simultaneous use of a telephone/headset and laptop/keyboard and sitting for extended durations.

• May be required to work additional hours beyond standard work schedule.

• Weekend Coverage may be required on a rotating basis as regulated for line of business.

• May require occasional weekend hours or evening hours as the needs of the business arise