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Point32Health · 1 day ago

Appeals and Grievance Analyst

Canton, MA

Full-time

Hybrid

Entry, Mid Level

$23.02/hr - $34.53/hr

2+ years exp

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. The Appeals and Grievance Analyst is responsible for the professional management and coordination of member appeals and grievances, ensuring compliance with State and Federal regulations while providing superior customer service. This role involves collaboration with members, providers, and internal teams to resolve complex issues and prepare documentation for appeals committees.

Health CareInsurance

Responsibilities

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 (National Committee for Quality Assurance), DOI (Dept of Insurance), 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

Perform other duties and projects as assigned

Qualification

Health care benefit knowledgeRegulatory compliance knowledgeCustomer service experienceInsurance product knowledgeAnalytical skillsInterpersonal skillsWritten communication skillsProblem-solving skillsTeam collaboration

Required

Associate's Degree or equivalent experience in health care, conflict resolution or related field

2-4 years' experience as a customer service or member services representative in health care or insurance

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

Preferred

Bachelors Degree in related field

2 years' Appeals and Grievance experience

Health care benefit and regulatory knowledge

Knowledge of insurance products, policies and procedures

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