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Health Alliance Plan · 3 hours ago

Appeal & Grievance Ops Analyst (Hybrid - Troy/MI) - Health Alliance Plan

Troy, MI

Full-time

Hybrid

Entry, Mid Level

2+ years exp

Health Alliance Plan is responsible for managing appeals, grievances, and complaints within the healthcare sector. The Appeal & Grievance Ops Analyst will analyze and assign cases, maintain regulatory compliance, and support the A&G staff with administrative duties and reporting.

Health CareHealth InsuranceInsuranceLife Insurance

Responsibilities

Ensures daily case receipt via mail, fax, email, Customer Message Center and HAP’s documentation application Pega (Customer Services Specialists), and vendor sites. Responsible for investigation, assignment and tracking for Appeals, Reconsiderations, Redeterminations, and Grievances and entry into care management system. Ensures adherence to CMS, NCQA, and DOL regulatory and compliance guidelines

Assists Appeal and Grievance Analyst in providing case data to support all internal and external reporting. Maintains the Access database as the source for departmental information to support Data Validation, NCQA, Medicare 5 Star, MARS and other initiatives

Responsible for providing all case documentation for External Review requests by DIFS, OPM, MAXIMUS, etc

Works with leadership to create and update Correspondences for Medicare Advantage and Commercial members and providers while ensuring compliance with regulatory entities

Works with Client Services Training department to create and maintain updated documents and desk level procedures to ensure new and current staff have resources available for continuing education

Provides administrative support to the Appeal and Grievance Manager and the Appeal and Grievance Analyst. Maintains professionalism and confidentiality and orders departmental supplies. Organizes and oversees the annual case purge performed by the Clerical team

Ensures meetings are scheduled as required and proper materials are prepared, distributed and presented as all meetings including but not limited to departmental, Grievance Pre Hearing and Grievance Committee Hearings

Performs record and document searches, collection and submission for the Legal Department

Creates statistical weekly, monthly and annual reports for Appeals and Grievances activity providing rationale when the activities are skewed; compile annual reporting data using charts and MS Power Point for distribution to internal leadership

Establishes and maintain strong relationships and contacts across departments in addition to external contacts to ensure open communication, team effort and positive work relations. Continues to self-educate on changes in policies and procedures that occur in other departments that could have an impact on the Appeal and Grievance department operations and the servicing of member/customers

Performs other related duties as assigned

Qualification

Appeals processingRegulatory complianceData analysisMicrosoft ExcelCustomer serviceMicrosoft WordMicrosoft PowerPointAccess databaseWindowsCommunication skills

Required

Associates Degree in Health Care, Business or related field required or 48 credit hours towards degree or an additional four (4) years of relevant and related experience may be considered in lieu of degree

Minimum of two (2) years of customer service experience in an office setting/call center

Demonstrated proficient use and knowledge of various software programs, such as Windows, Microsoft Word, Microsoft Excel, and Access

Minimum of 2 years' experience reviewing and processing the intake of appeals, grievances, and claims inquiries

Mail screening required for all lines of business with emphasis on contracted and noncontracted provider appeals that include knowledge of medical appeals, claims investigation and denial reasons within the claims payment system