Appeals & Grievance Analyst
Quincy, MA 02169 | Temporary
Job Type: Temporary/Contract (10 months+)
ACE Employment is working with a client in Quincy looking to hire an Appeals & Grievance Analyst. In this contract role you will be responsible for the management and coordination of assigned member appeals and formal complaints received. You will work collaboratively with the member and/or the member’ s authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions.
- Act as a member advocate; clearly communicating the appeal and complaints process and procedures both orally and in writing.
- Manage assigned member appeals and formal complaint cases from documentation, to investigation, and through resolution.
- Review and interpret product and benefit designs by state and employer group
- 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
- Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented
- Recommend approval or denial of any member’ s requests based on the member’ s contract, available benefits and individual circumstances presented.
- Facilitate clinical cases for review by an Independent Review Organization (IRO).
- Insure all adverse determinations are reviewed for medical necessity by Utilization Management Department following guidelines established by NCQA and/or any state specific regulatory requirement.
- Insure the final disposition of a member’ s appeal or complaint is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state specific regulations that apply.
- Develop case files and written documentation to member regarding final disposition of appeal or formal complaint that is fully compliant with all NCQA and state mandated requirements. Utilize appropriate technology to document all actions taken in the resolution of an appeal or complaint.
- Responsible for effectuation of all appeal and complaint decisions (i.E. Authorizations, claims payment)
- Facilitate IRO level review according to Federal Health Care Reform.
- Prepare cases weekly that are thoroughly researched, documented and summarized for discussion and final decision. Actively participates on each committee as needed.
- Provide subject matter expertise and support to Member Services as well as for regulatory agency site visits.
- Bachelors 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
- Superior investigation, analytical and problem solving skills
- Excellent customer service and interpersonal skills
- Knowledge of insurance products, policies and procedures, and claims process.
- Working knowledge of plan products and benefits and the ability to communicate this information to members, providers, employers and external agencies clearly and concisely.
- Strong computer, analytical, written and oral communication skills.
- Ability to work independently and collaborate as part of a team