The Grievance and Appeals Analyst responds to grievances and appeals to ensure the resolutions are consistent with organizational policies and procedures and which are compliant with state and federal guidelines and also ensures due process rights. The Analyst synthesizes and analyzes all available data which may contain multiple issues and may require coordination of responses from multiple business units. The Analyst ensures timely, customer focused responses to complaints and appeals, identifies trends and emerging issues, reports and recommends solutions. Works with internal and external customers to gather and verify information related to consumer safety and provider compliance. Identifies critical issues and triages issues appropriately to ensure that urgent member needs are met expediently. Communicates trends and actionable analysis to appropriate parties in a timely manner.
This position will allow the successful candidate to work a remote schedule and be a resident of North Carolina. There is no expectation of being in the office routinely.
Responsibilities & Duties
Management of General Functions
Responsible for receiving and monitoring information related to provider quality assurance issues including but not limited to grievances, quality of care concerns, and/or appeals
Works to ensure comprehensive quality assurance information is available to agency staff/departments as needed
Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources
Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision
Works independently to mediate complex relationships between multiple external and internal stakeholder so that all parties are satisfied with identified resolutions
Ensures resolutions of issues related to member experiences are compliant with local, state and federal regulations
Utilizes various internal and external data platforms to perform a thorough analysis of issues related to member experiences
Utilizes professional communication skills to provide information to internal and external stakeholders verbally and in writing
Management of Grievances
Monitors timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes
Uses analytical skills to define recommendations and improve practices
Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff; Trains internal and external customers on quality assurance reporting requirements
Reviews policies and procedures and makes recommendations for changes/edits in alignment with current guidelines and requirements
Collaborates with internal staff to ensure all relevant information is available for consideration
Management of Appeals
Prepares and ensures timely mailing of receipt of appeal and outcome notification letter to the individuals/ guardians and providers based on the most current formats and timeline requirements
Tracked appeal requests and assignment of the local reconsideration review process through resolution
Maintains all denial and appeals files in a an accessible manner
Participates in the development of internal training on Denial and Appeals as determined by the internal and external quality reviews
Aids legal counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in the appeals process
Ensures Alliance staff are prepared for mediation and hearings by preparing and organizing all legal and clinical documents for 2nd level appeals
Assists in the discovery process with Alliance’s legal department and draft Office of Administrative Hearings (OAH) documents
Schedules mediation hearings and documents the process and outcomes
Provide training and technical assistance to staff regarding Due Process rules
Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definition and clinical guidelines when making appeal determinations
Writes, edits, and/or coordinates the preparation of correspondence, reports, or other printed material according to well established standards or readily available
Performs other related duties as assigned
Minimum Requirements
Education & Experience
A minimum of a Bachelor’s degree from accredited college or university with a major in mental health, public health, psychology, sociology, public administration, management information systems, statistics, or a related field. A minimum of two years working human services/behavioral health post bachelor’s degree and/or a minimum of two years of experience analyzing data sets, interpreting and synthesizing data into a report format, and working with teams/units to integrate data information needs.
Knowledge, Skills, & Abilities
Knowledge of Federal and State regulations on Behavioral Healthcare grievances and appeals processes
Knowledge on medical records practices and records keeping practices
Knowledge of legal proceedings including mediation, administrative law courts, and other legal processes
Demonstrated proficiency in personal computer use and MS Excel
Some familiarity with other software packages, such as SPSS and MS Word, Project, Publisher, PowerPoint, and BI is desired
Must have good oral, written, and graphic presentation skills
Must demonstrate understanding of data analysis and techniques
Demonstrated ability to learn new software and user capabilities
Ability to integrate programmatic information into required data sets for analysis and interpretation
Ability to work well with others in a fast-paced, and sometimes stressful, environment
Experience with customer service, provider relations or similar activities is preferred
Experience working with individuals with mental health, substance abuse issues, and/or intellectual disabilities preferred
Salary Range
$25 - $32.50/Hourly
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
