Grievance Analyst

Green Key resources is representing a healthplan who is seeking a highly motivated and detail-oriented Grievance Analyst to join their team remotely.

Monday - Friday 8am - 5pm EST

Key Responsibilities:

• Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received.
• 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.
• This individual 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 Appeals Committee discussion when needed.
• Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member’s appeal or grievance providing further appeal options as appropriate.
• Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary.
• The employee must have the ability to learn and apply policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed.
• The Analyst is responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by members for all lines of business.

DUTIES/RESPONSIBILITIES – what you will be doing (top five):

· 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 the final disposition of a member’s appeal or grievance is compliant with the regulatory requirements set-forth by NCQA, DOI, CMS, DOL and any state or federal specific regulations that apply.

· 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.

QUALIFICATIONS – what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE:

· Associates Degree or equivalent experience in health care, conflict resolution or related field

EXPERIENCE (minimum years required):

· 3-5 years health care or insurance experience

· Health care benefit and regulatory knowledge preferred

· Knowledge of insurance products, policies and procedures preferred.

If you are passionate about healthcare and have experience in Medicare Grievances, we encourage you to apply for this exciting opportunity.

Job Type: Full-time

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Application Question(s):

• What is your target salary range?
• What is your current zip code?
• What is the best number to call you at to schedule an interview?
• Aside from your resume, please provide any detail regarding your experience handling Medicare Grievances.

Work Location: Remote