Appeals and Grievances Analyst

Associate III – BPM

 

Who We Are:

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

 

You Are:

The Appeals and Grievance Analyst, acting in a quality assurance capacity, is responsible for the processing Appeals and Grievances by evaluating the organization's initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case. All Appeals and Grievance cases must be documented in the highest quality possible, ensuring the Appeals and Grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations.

 

The Opportunity:

·       Follows Grievances and Appeals processes and systems to ensure data quality to support UST HealthProof’s quality, production, and financial goals.

·       Investigate and thoroughly document findings on all grievances and appeals.

·       Prepare Appeal case recommendations for initial review process.

·       Coordinate appropriate reviewer assignment for Appeals and Grievance cases.

·       Responsible to move Appeals and Grievances through each review level to ensure timely completion.

·       Bring to management’s attention any system or process issues determined during the investigation of the appeal or grievance.

·       Coordinate effectively with the Information technology department on upgrades/fixes/changes

·       Participate in the departmental audit/oversight program that focuses on continuous quality improvement.

·       Participate in compliance committees to help continuously improve initial decision making.

 

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

 

What You Need:

·       Bachelor’s degree in Business Administration, Economics, Health Care, Information Systems, Statistics or other related field is required.

·       Master’s Degree in related field preferred. Certification or progress toward certification is highly preferred and encouraged.

·       Five years experience in a grievance and appeals environment including experience with the grievance and appeals regulations per CMS.

·       Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans.

·       Experience working in or with Medicare Advantage plans, or Independent Review Entities.

·       Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes.

·       Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred.

·       Knowledge in claims, authorizations, and Medicare Advantage plans.

·       Proven problem solving skills and ability to translate knowledge to corporate departments.

·       Strong communication skills are required to understand, interpret, and communicate ideas.

·       Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc).

·       Working knowledge of data languages such as SAS or SQL.

·       Strong analytical, organizational, planning and problem solving skills.

·       Ability to effectively interface with employees at all levels.

·       Understand and apply statistical inference.

·       Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.

·       Ability to write reports and correspondence.

·       Ability to speak effectively before groups of customers or employees of organization.

·       Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.

·       Ability to define problems, collect data, establish facts, and draw valid conclusions.

·       Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

·       Demonstrated track record of generating results and having an impact on organizations.

·       Strong focus and drive to serve the customer.

·       Ability to work in a high paced environment.

·       Ability to consistently exceed deadlines.

 

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range:   $37,440-$43,680

 

 

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, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching.

Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.

Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).

All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

·       Simplicity

Simplifying complexity underlines everything we do—this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

·       Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

·       People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

·       Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and “fair chance” ordinances.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

 

 

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