Unfortunately, this job posting is expired.
Don't worry, we can still help! Below, please find related information to help you with your job search.
Don't worry, we can still help! Below, please find related information to help you with your job search.
Related keywords
Some similar recruitments
Hospital Denials/Medical Appeals Specialist
Recruited by Beth Israel Lahey Health 8 months ago
Address Burlington, MA, United States
Appeals & Grievances Analyst Jobs
Recruited by Point32Health 9 months ago
Address Massachusetts, United States
Rn Clinical Liaison Jobs
Recruited by Gentiva Hospice 9 months ago
Address Auburndale, MA, United States
Member Appeals & Grievances Intake Administrator
Recruited by Fallon Health 11 months ago
Address Worcester, MA, United States
Appeals & Grievances Analyst Jobs
Recruited by Point32Health 1 year ago
Address Everett, MA, United States
Appeals & Grievances Analyst Jobs
Recruited by Point32Health 1 year ago
Address Natick, MA, United States
Appeals & Grievances Analyst Jobs
Recruited by Point32Health 1 year ago
Address Green Harbor, MA, United States
Appeals & Grievances Analyst Jobs
Recruited by Point32Health 1 year ago
Address Boston, MA, United States
Appeals & Grievances Analyst Jobs
Company | Point32Health |
Address | Dighton, MA, United States |
Employment type | FULL_TIME |
Salary | |
Category | Insurance |
Expires | 2023-06-13 |
Posted at | 1 year ago |
Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual works collaboratively with the member and/or the member’s authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation, discussion, review and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include 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. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues.
- Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
- 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
- Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements
- Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
- 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, DOI, CMS, DOL and any state or federal specific regulations that apply.
- Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
- Associates Degree or equivalent experience in health care, conflict resolution or related field
- 3-5 years health care or insurance experience
- Health care benefit and regulatory knowledge preferred
- Knowledge of insurance products, policies and procedures preferred.
- Working knowledge of plan products and benefits and the ability to communicate this information to members, providers, employers and external agencies clearly and concisely.
- 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.
- Ability to work independently and collaborate as part of a team
- Superior investigation, analytical and problem-solving skills
- Excellent customer service and interpersonal skills
- Requires ability to understand and be compliant with State and Federal regulations.
- Requires excellent interpersonal skills in order to communicate and work with multiple constituents.
- Must possess initiative, balanced judgment, objectivity and the ability to independently plan and prioritize one’s own work to assure maximum efficiency and compliance.
- 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.
- 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
- Work requires simultaneous use of a telephone/headset and laptop/keyboard and sitting for extended durations.
- Must be able to work under normal office conditions and in a remote capacity from home as required.
- 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 various lines of business dictate.
-
Systems Analyst - Excel, Xml, Sql, Scripting
By CyberCoders At Salt Lake City, UT, United States 8 months ago
-
(Senior) Finance & Shared Services Manager
By Catholics For Choice At Washington, DC, United States 8 months ago
-
Paralegal - Probate Administration
By CyberCoders At Miami, FL, United States 8 months ago
-
Account Executive - Automotive Software
By ECW Search At United States 8 months ago
-
Construction Project Coordinator Jobs
By CyberCoders At River Falls, WI, United States 8 months ago