The Appeals and Grievance Analyst, acting in a quality assurance capacity, is responsible for the processing Appeals and Grievances by evaluating the organization's initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case.

 

RESPONSIBILITIES

Follow processes and systems to ensure data quality to support quality, production, and financial goals Investigate and thoroughly document findings on all grievances and appeals Prepare appeal case recommendations for initial review process Coordinate appropriate reviewer assignment for appeals and grievance cases Move appeals and grievances through each review level to ensure timely completion Drive operational excellence into all processes and departmental interactions based on requirements Bring to management’s attention any system or process issues determined during the investigation of the appeal or grievance Coordinate effectively with the Information Technology department on upgrades/fixes/changes Participate in the departmental audit/oversight program that focuses on continuous quality improvement Participate in compliance committees to help continuously improve initial decision making

 

REQUIREMENTS

5 years’ experience in a grievance and appeals environment, including experience with the grievance and appeals regulations per CMS Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans Experience working in or with Medicare Advantage plans, or Independent Review Entities Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred