Appeals & Grievance Analyst - Internal Applicants Only
Tracking Code
291096-561
Job Description
INTERNAL EMPLOYEES ONLY
The Member Appeal and Grievance Analyst is responsible for the management and coordination of assigned member appeals and formal complaints received at HPHC. The Appeals and Grievance Analyst works collaboratively with the member and/or the member s authorized representative and must demonstrate superior customer service skills in all interactions. The Appeals and Grievance Analyst prepares cases for presentation, discussion, review and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Committee discussion when needed. Prepares all written documentation and correspondence to the member outlining final disposition of the member s appeal or grievance providing further appeal options as appropriate.
ESSENTIAL FUNCTIONS:
* Acts as a member advocate who is able to clearly communicate the appeal and complaints process and procedures both orally and in writing.
* Responsible for complete documentation, investigation and resolution of member appeal or formal complaint case assigned. All appeals are logged and tracked in JIVA. All complaints are logged and tracked in XRM.
* Facilitates the collection of all documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customers.
* Reviews the documents for information specific and relative to the request. Obtains latest supporting information as it becomes available.
* Reviews and interprets product and benefit designs by state and employer group.
* Consults with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented. Maintains knowledge of resources available within organization to assist in appeal and complaint resolution.
* Recommends approval or denial of any member s requests based on the member s contract, available benefits and individual circumstances presented.
* Knowledge of plan products and benefits and the ability to communicate this information to members, providers, employers and external agencies clearly and concisely.
* Insures all adverse determinations are reviewed for medical necessity by Utilization Management Department following guidelines established by NCQA and/or any state specific regulatory requirement.
* Insures 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.
* Creation of case files and written documentation to member regarding final disposition of appeal or formal complaint that is fully complaint with all NCQA and state mandated requirements. Utilizes 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)
* Facilitates transfer of all case documents to external review agency as requested.
* Prepares cases for MAC and MARC weekly that are thoroughly researched, documented and summarized for discussion and final decision. Actively participates on each committee as needed.
* Provides content knowledge and support to Member Services.
MINIMUM REQUIREMENTS:
Education:
Bachelors Degree or equivalent experience in health care, conflict resolution or related field
Experience:
3-5 years health care or insurance experience required
Preferred Skills/ Qualifications:
Health care benefit and regulatory knowledge preferred
Skills/ Competencies:
Must possess superior investigation, analytical and problem solving skills
Knowledge of insurance products, policies and procedures, and claims process.
Strong computer, analytical, written and oral communication skills. Strong customer service skills.
Strong command of the English language as well as excellent written communication skills
Other Skills:
Ability to work independently and collaborate as part of a team
Job Location
Quincy, Massachusetts, United States
Position Type
Full-Time/Regular
CORI
Yes
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