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Point32Health · 1 day ago

Appeals and Grievance Analyst

Canton, MA

Full-time

Onsite

Mid Level

$23.02/hr - $34.53/hr

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. The Member Appeals and Grievance Analyst is responsible for the professional management and coordination of member appeals and grievances, ensuring compliance with regulations while providing superior customer service.

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, 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

Qualification

Regulatory complianceCustomer serviceBenefit interpretationDocumentation managementCase managementAnalytical skillsCommunication skillsCollaboration skills

Required

Demonstrate superior customer service and benefit interpretation skills in all interactions

Ability to learn and apply Point32Health's policies and remain compliant with frequently changing State and Federal regulatory requirements

Judgment to seek out guidance as needed

Accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for all lines of business

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