Grievance and Appeals Analyst

Grievance and Appeals Analyst

W2 Contract

Salary Range: $68,600 - $79,000 per year

Location: South San Francisco, CA - Onsite Role

Job Summary:

As a Grievance and Appeals Analyst, you will provide department-specific analysis and quality assurance, including analyzing data and processes to identify trends related to operational or quality issues, identifying and implementing process improvements, and supporting departmental training efforts.

Duties and Responsibilities:

• Utilize G&A data to identify trends and root causes of repeat issues brought to the G&A unit; advocate for members, summarizing insights and clearly communicating quality monitoring results to the team; clearly communicate findings from trend analysis with G&A management and other internal customer groups.
• Partner with team Lead and supervisor to trend and conduct thorough reviews of G&A casework in alignment with regulations, internal training, and standard operating procedures.
• Design, develop, and produce visualizations of data reports such as tables, graphs, and charts to support reporting and analysis.
• Write parameters for all G&A reports, including all reports provided to regulatory bodies (i.e., Department of Health Care Services, Department of Managed Health Care, and Centers for Medicare and Medicaid Services) and governing bodies (e.g., Consumer Advisory Committee).
• Maintain department desktop procedures, workflows, job aids, and training material.
• Identify barriers to work processes and bring them to the attention of the Supervisor/Manager.
• Analyze, create, and test new tools and processes to enhance the department's assessment and documentation processes. Develop and implement work plans for department and individual staff under the direction of the G&A Supervisor and Manager; identify appropriate resources for tasks and develop appropriate workflows and outcomes.
• Identify and help implement staff training that addresses team needs in collaboration with the Lead and Supervisor; this includes:
• Analyzing and providing written/verbal interpretation of data to identify new team training needs
• Assisting with the design of new trainings for the team
• Provide ongoing training and assistance to internal staff, as assigned, on how to effectively process grievances and appeals to DHCS and CMS requirements.
• Providing recommendations to support the Supervisor and Manager in creating tailored individual training plans.
• Under the direction of the G&A Supervisor and Manager, leads team preparation for audits and designated responses to regulatory agencies.
• Research issues related to assigned projects, including regulatory compliance, to identify their impact on the organization.
• Develops and maintains collaborative relationships within the unit and inter-departmentally; collaborates with the Health Information Management (HIM) team to ensure all G&A reporting is accurate and conducts quality assurance on the data provided.
• Continuously evaluates processes and recommends to the G&A Manager for ongoing process improvement, including database design and staff training.
• As needed, provide backup coverage and support for other team members.

Requirements and Qualifications:

• Bachelor's Degree preferred.
• 3 years of experience in managed care and/or grievance and appeal (Healthcare environment).
• Medicare/Medicaid experience preferred.
• Subject-matter expertise in training and facilitation skills in a group/ classroom setting and one-on-one preferred.
• Knowledge of:
• Quantitative and qualitative analysis
• Database management, spreadsheets, relational databases, and healthcare-compliant systems
• Local, state, and federal health plan guidelines/regulations (including CMS, DMHC, DHCS, and NCQA requirements)
• Personal computers and Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint
• Grievance and Appeals processes and concepts in a health insurance managed care setting.
• Healthcare processes related to maintaining regulatory compliance
• Able to:
• Prioritize multiple and competing tasks in a fast-paced and dynamic environment.
• Work under pressure and meet deadlines.
• Work both independently and in a team environment.
• Communicate effectively, both verbally and in writing.
• Analyze data and create reports by utilizing strong analytical skills with high attention to detail.
• Communicate effectively, with a strong emphasis on written and verbal communication.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Exercise objectivity in all work functions and approach conflict with curiosity.
• Collaborate and build relationships with various people as part of a cross-functional team.
• Demonstrate a strong customer focus and proactively find ways to exceed customer needs.
• Skills:
• Excellent written and oral communication skills and strong interpersonal, critical thinking, and analytical skills.
• Excellent organizational, decision-making, and multi-tasking skills
• Keen attention to detail

Desired Skills and Experience

Healthcare, Grievance and Appeals, CMS, DMHC, DHCS, NCQA, auditing, Excel, Microsoft Office, database management, relational databases, regulatory

Bayside Solutions, Inc. is not able to sponsor any candidates at this time. Additionally, candidates for this position must qualify as a W2 candidate.

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