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. All Appeals and Grievance cases must be documented in the highest quality possible, ensuring the Appeals and Grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations.
- Follows Grievances and Appeals processes and systems to ensure data quality to support Advantasure's 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.
- Responsible to move Appeals and Grievances through each review level to ensure timely completion.
- Drive operational excellence into all processes and departmental interactions based on CMS and Advantasure 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.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.EMPLOYMENT QUALIFICATIONS: EDUCATION OR EQUIVALENT EXPERIENCE:
Bachelor's degree in Business Administration, Economics, Health Care, Information Systems, Statistics or other related field is required. Master's Degree in related field preferred. Relevant combination of education and experience may be considered in lieu of degree. Certification or progress toward certification is highly preferred and encouraged.EXPERIENCE:
Five 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.SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:
- Knowledge in claims, authorizations, and Medicare Advantage plans.
- Proven problem solving skills and ability to translate knowledge to corporate departments.
- Strong communication skills are required to understand, interpret, and communicate ideas.
- Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc).
- Working knowledge of data languages such as SAS or SQL.
- Strong analytical, organizational, planning and problem solving skills.
- Ability to effectively interface with employees at all levels.
- Understand and apply statistical inference.
- Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
- Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
- Demonstrated track record of generating results and having an impact on organizations.
- Strong focus and drive to serve the customer.
- Ability to work in a high paced environment.
- Ability to consistently exceed deadlines.
Work is performed both in the office and in the field with minimal hazards. Minimal travel required. May be required to lift and carry up to 35 lbs.
The qualifications listed above are intended to represent the minimum education, experience, skills, knowledge and ability levels associated with performing the duties and responsibilities contained in this job description.
We are an Equal Opportunity Employer. Diversity is valued and we will not tolerate discrimination or harassment in any form. Candidates for the position stated above are hired on an \"at will\" basis. Nothing herein is intended to create a contract.
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