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Role Description

Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst is responsible for the professional and compliant management and coordination of assigned member appeals and grievances (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.

• Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring compliance with regulatory requirements set forth by NCQA, DOI, CMS, DOL, and applicable state or federal regulations.
• Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements.
• 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.
• Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
• Perform other duties and projects as assigned.

Qualifications

• Required (minimum): Associate’s Degree or equivalent experience in health care, conflict resolution, or related field
• Preferred: Bachelor’s Degree in related field
• Required (minimum): 2-4 years' experience as a customer service or member services representative in health care or insurance
• Preferred: 2 years’ Appeals and Grievance experience
• Health care benefit and regulatory knowledge preferred.
• Knowledge of insurance products, policies, and procedures preferred.
• 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.
• Must possess initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize one’s own work to assure maximum efficiency and compliance.
• 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.
• 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.
• Requires excellent interpersonal skills to communicate and work with multiple constituents.
• Requires ability to understand and be compliant with State and Federal regulations.
• Superior investigation, analytical, and problem-solving skills.
• Excellent customer service and interpersonal skills.
• Ability to work independently and collaborate as part of a team.

Requirements

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• 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.

Benefits

• Medical, dental, and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

Salary Range

$22.96 - $34.45

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay.

We welcome all

All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert

Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment.