UST HealthProof · 20 hours ago
Appeals & Grievances Analyst
United States
Full-time
Remote
Mid Level
$40K/yr - $45K/yr
3+ years expUST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. The Appeals & Grievances Analyst is responsible for managing and resolving member and provider appeals and grievances in compliance with CMS regulations, ensuring timely and accurate case processing while maintaining exceptional service standards.
Hospital & Health Care
Responsibilities
Review, analyze, and resolve member and provider appeals and grievances in accordance with CMS guidelines and Medicare Advantage requirements
Ensure compliance with federal and state regulations, organizational policies, and contractual obligations
Conduct detailed case investigations, gather supporting documentation, and prepare comprehensive case summaries
Communicate resolution outcomes to members, providers, and regulatory agencies in a clear and professional manner
Collaborate with internal departments (Claims, Utilization Management, Compliance) to ensure accurate and timely case handling
Monitor regulatory changes and assist in implementing process improvements to maintain compliance
Prepare reports and maintain accurate documentation for audits and regulatory submissions
Qualification
Required
High School Diploma required
Minimum of 3 years of experience in a grievance and appeals environment, with strong knowledge of CMS regulations
Experience in medical benefits, claims processing, authorizations, and Medicare Advantage plans
Familiarity with Independent Review Entities (IREs) and CMS appeals/grievance processes
In-depth understanding of CMS regulations and Medicare Advantage requirements
Ability to review complex cases and apply regulatory standards accurately
Skilled in case management systems, claims platforms, and Microsoft Office Suite
Strong written and verbal communication skills for member/provider correspondence and regulatory reporting
Ability to identify issues, recommend solutions, and make sound decisions under strict timelines
Excellent time management and prioritization to handle multiple cases efficiently
Self-starter
Preferred
Bachelor's degree in business administration, Healthcare Management, or related field preferred
Experience with HIPAA compliance and privacy regulations highly preferred
Benefits
Full-time, regular employees accrue up to 16 days of paid vacation per year
Receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year)
10 paid holidays
Eligible for paid bereavement leave
Eligible to participate in the Company’s 401(k) Retirement Plan with employer matching
Eligible for medical, dental, and vision insurance
Basic life insurance
Accidental death and disability insurance
Short- and long-term disability benefits
May purchase additional voluntary short-term disability benefits
Participate in a Health Savings Account (HSA)
Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses
Potential for quarterly incentive-based bonuses and or commissions depending on role
Company
UST HealthProof
UST HealthProof offers risk adjustment, quality programs, and healthcare payer technology services. It is a sub-organization of UST.
501-1000 employees
Funding
Current Stage
Late StageTotal Funding
unknown2025-09-04Acquired
Leadership Team
Kevin Adams
Chief Executive Officer
Beth Maxwell
VP Product Delivery and Partnerships
Recent News
2025-12-06
Precedence Research
2025-11-21
2025-11-07
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