Grievance, Claims & Appeals Analyst

**Fully REMOTE Opportunity**

Job Summary Details

· The Grievances and Appeals Analyst I will be responsible for investigating and resolving member, Health Plan Partner-member and network provider grievances and appeals.

· Identify, analyze and research both pre- and post-service denials for both members and providers to identify discrepancies, errors, etc. and to determine appropriate course(s) of action.

· Process all appeals within regulatory guidelines.

· Respond in writing to members and providers, making informed judgements on the proper application of members’ dental plan benefits, accurate adjudication of claims and referrals and other potential issues by conducting timely, thorough investigations of assigned grievances and appeals cases.

· Verify information related to data entry, claims submissions, authorizations and workflow processes to ensure timely reimbursement to members and providers when necessary.

· Demonstrate team-oriented attitude by following directions from Supervisor, interacting well with co- workers, accepting and following work rules and procedures, complying with corporate policies, goals and objectives, accepting constructive feedback and exhibiting initiative and accountability for their work.

· Interface with other internal and external entities, ensuring a positive and professional relationship.

· The Grievances and Appeals Analyst I will also be responsible for occasional intake of all member and provider grievances and appeals.

Distinguishing Characteristics

· Distinguishing Characteristics for G&A Analyst II

· The Grievance and Appeals Analyst II will act as a subject matter expert to the Grievance and Appeals Analyst I regarding grievances and appeals and will collaborate within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.

· Performing the job duties of the Grievance and Appeals Analyst I position, detailed above.

· Receive and respond to department staff questions and concerns, demonstrating sound judgement and communication clear instructions to team members.

· Assist with any training that department staff members may require.

· Follow and implement all directive, policies and procedures.

· Identify areas of concern and assist with the development and implementation a strategy for the department to reach its goals.

· Respond in writing to all levels of grievances and appeals, including fair hearings.

· Distinguishing Characteristics for G&A Analyst III

· The Grievance and Appeals Analyst III will be responsible for investigating and resolving highly complex member, Health Plan Partner-member and network provider grievances and appeals such as disputes involving high reimbursement amounts and/or complex quality of care cases.

· Respond to all levels of regulatory complaints, such as those from the Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS) or Department of Insurance (DOI).

· Investigate and perform the job duties as the Grievance Analyst I and II, detailed above.

· Monitor all incoming notices of requests for fair hearings or requests for Health Plan Information (RHPI) from the DMHC, DHCS or DOI.

· Communicate directly with members, providers and Health Plan partners when necessary to obtain additional information and/or providing updates regarding the progress of active and open cases.

· Assist with monitoring daily operations of the Grievance Team when a Team Lead, Supervisor or Manager is out of the office.

· Aid the Supervisor/Manager with developing and maintaining grievance policies, procedures and compliance assessments.

· Attend monthly/quarterly Grievance Committee meetings. Prepare and present agenda items as assigned by Supervisor/Manager.

Education Requirements

Min/Preferred

Education Level

Description

Minimum

High School or GED

Years of Experience

Minimum Years of Experience

Maximum Years of Experience

Comments

3 years of dental background

2 years of office administrative support experience in healthcare

Specific Skills/Knowledge

· Dental Insurance Plan experience highly preferred.

· Experience in a Quality Management Department preferred.

· Excellent time management skills are required, along with the ability to meet strict internal and regulatory deadlines, while working independently in a fast-paced environment and maintaining superior work quality.

· Intermediate knowledge in Microsoft Word and Excel.

· Excellent written communication skills, with the ability to draft professional business correspondence directed toward a wide variety of audiences, from laymen to doctors, is required.

· Strong verbal communication and customer service skills, particularly as it relates to processing member and provider grievances and appeals.

· Demonstrate ability to work independently, prioritize workload and maintain strong business relationships.

· Strong working knowledge of applicable laws and regulations, including current appeals guidelines established by the Centers for Medicare and Medicaid Services (CMS), and the ability to research Medicare and Medicaid regulations to ensure compliance and protect the company from sanctions, enforcement actions and penalties.

· Availability to work overtime when required.