Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Grievance/Appeals Analyst I is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) 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:
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.
The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation.
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.
Minimum Requirements
HS diploma or GED
Minimum of 3 years experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences
Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly preferred.
Prior claims experience preferred.
ACMP and Pega experience 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.
