Candidates must be located within 50 miles of Atlanta, GA, Miami, FL, Mason, OH, Norfolk, VA, Tampa, FL, or Topeka, KS
The Grievance/Appeals Analyst Lead is responsible for leading and coaching a team of Grievance & Appeals Analysts in the Enterprise Grievance & Appeals Department responsible to review, analyze and process pre service and post service grievances and appeals requests related to clinical and non clinical services, quality of service and quality of care issues to include executive and regulatory grievances.
How you will make an impact:
Monitors work flow and makes assignments to ensure the correct team resource is utilized to achieve accreditation and regulatory compliance metrics in a quality manner.
May also be responsible to provide review and analysis of complex pre service and post service grievances and appeals requests from customer and multiple products related to clinical and non clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.
Coaches, trains, and audits to ensure the team correctly 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.
Minimum Requirements:
Requires a high school diploma or GED equivalent and a minimum of 3 years of Grievance & Appeals Senior analyst experience; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences:
Associate's or BA/BS degree preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
