JOB SUMMARY

The Appeals and Grievance Analyst performs research, investigation and analysis of appeals, grievances, and other types of complaints filed by members and customers to administer timely resolution within state and federal guidelines, benefit plan guidelines, and company policies and procedures. The analyst is expected to maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with any type of complaint and to make no disclosures of such information except to persons authorized to receive it in the conduct of business.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Ensures timely review, research and resolution of appeals, grievances and complaints within guidelines. Ensures that all complaints are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy. Detailed documentation of all research and findings in case files and corresponding trackers with no grammatical errors for easy and accurate retrieval. Make and receive inbound and outbound calls as needed to members, providers, etc. using call tracking platform.
• Consult, collaborate and communicate with medical directors and various departments (i.e. Member Services, Care Management, Claims, Appeals Review Committee), as well as external entities (i.e. Providers and Vendors) to collect initial and subsequent information as needed. Works independently to complete tasks.
• Initiate claim adjustments, provider education, etc. when necessary and follow and track until completion.
• Log and track grievances, appeals, and other types of complaints as needed. Prepares and generates complaint case files and mails letters, forms, and other complaint related notices. Analyze, track and trend patterns and areas of concerns to management.
• Other duties as assigned.

EDUCATION AND EXPERIENCE

Education:

• High School Diploma or GED

Required Experience:

• One (1) or more years of health plan experience
• Proficient in Word, Excel, and PowerPoint

Preferred Experience:

• Associate degree
• One (1) or more years of Medicare Part C& D experience
• Medicare Advantage Appeals and Grievance experience
• Experience working with regulatory agencies and in a compliance environment
• Experience interacting with other healthcare professionals and proficiency in medical and pharmacy terminology

Other Requirements:

• Annual Flu Vaccine

KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

• Customer service experience in managed care setting
• Strong in the following competencies:
  • Time management
• Ability to work independently, Availability to work after normal business hours, including weekends and holidays
  • Decision making/Judgment
  • Problem solving/Analysis
  • Communication, written and oral
  • Organizational skills

Preferred Competencies:

• Prior appeals & grievance related work

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• A negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Benefits from Day One: 

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind.

ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.