Description
We’re building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.
The Complaints & Appeals Analyst is responsible for reviewing, investigating, and resolving member complaints, appeals, and grievances.
Responsibilities
- Reviews and investigates member complaints, appeals, and grievances in accordance with established policies and procedures.
- Analyzes case information, supporting documentation, and benefit information to determine appropriate case outcomes.
- Prepares accurate and timely written correspondence related to complaint and appeal determinations.
- Ensures cases are processed within established quality, productivity, and turnaround time standards.
- Researches and resolves complex issues by collaborating with internal business partners and applicable stakeholders.
- Maintains accurate and complete case documentation in applicable systems.
- Identifies potential trends or process concerns and escalates issues as appropriate.
- Participates in departmental projects, training, and process improvement initiatives.
- Supports compliance with federal and state regulations and internal policies governing complaint and appeal activities.
Required Qualifications
- 5+ years of work experience with Medicaid Complaint & Appeals
- Strong analytical, problem-solving, and decision-making skills.
- Excellent written and verbal communication skills.
- Ability to manage multiple priorities and adhere to established deadlines.
- Proficiency in Microsoft Office applications.
Preferred Qualifications
- Experience in healthcare, insurance, claims, customer service, complaints and appeals, or related operations.
- Experience researching and resolving complex customer or member issues.
- Knowledge of health plan benefits, claims, and appeals processes preferred.
Education
- High school diploma or equivalent required.
Benefits
- Medical, dental, and vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
Pay Range
- $18.50 - $35.29
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