Acting in a quality assurance capacity, Appeals and Grievances Analysts are responsible for 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.

Responsibilities:

Follow Grievances and Appeals processes and systems to ensure data quality to support UST’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 Drive operational excellence into all processes and departmental interactions based on CMS and UST requirements 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

 

Requirements:

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. Relevant combination of education and experience may be considered in lieu of degree Certification or progress toward certification is highly preferred and encouraged 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 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 analytical, organizational, planning, and problem-solving skills Ability to effectively interface with employees at all levels Ability to define problems, collect data, establish facts, and draw valid conclusions 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 meet deadlines