The Grievance and Appeals Analyst responds to grievances and appeals to ensure the resolutions are consistent with organizational policies and procedures and which are compliant with state and federal guidelines and also ensures due process rights. The Analyst synthesizes and analyzes all available data which may contain multiple issues and may require coordination of responses from multiple business units. The Analyst ensures timely, customer focused responses to complaints and appeals, identifies trends and emerging issues, reports and recommends solutions. Works with internal and external customers to gather and verify information related to consumer safety and provider compliance. Identifies critical issues and triages issues appropriately to ensure that urgent member needs are met expediently. Communicates trends and actionable analysis to appropriate parties in a timely manner.
This position is full-time remote. Selected candidate must reside in North Carolina and be willing to travel to the home office (Morrisville, NC) for onsite team meetings as needed.
Must have the flexibility to work weekends and holidays to fit the business needs.
Responsibilities & Duties
Management of General Functions
- Responsible for receiving and monitoring information related to provider quality assurance issues including but not limited to grievances, quality of care concerns, and/or appeals
- Works to ensure comprehensive quality assurance information is available to agency staff/departments as needed
- Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources
- Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision
- Works independently to mediate complex relationships between multiple external and internal stakeholder so that all parties are satisfied with identified resolutions
- Ensures resolutions of issues related to member experiences are compliant with local, state and federal regulations
- Utilizes various internal and external data platforms to perform a thorough analysis of issues related to member experiences
- Utilizes professional communication skills to provide information to internal and external stakeholders verbally and in writing
Management of Grievances
- Monitors timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes
- Uses analytical skills to define recommendations and improve practices
- Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff; Trains internal and external customers on quality assurance reporting requirements
- Reviews policies and procedures and makes recommendations for changes/edits in alignment with current guidelines and requirements
- Collaborates with internal staff to ensure all relevant information is available for consideration
Management of Appeals
- Prepares and ensures timely mailing of receipt of appeal and outcome notification letter to the individuals/ guardians and providers based on the most current formats and timeline requirements
- Tracked appeal requests and assignment of the local reconsideration review process through resolution
- Maintains all denial and appeals files in a an accessible manner
- Participates in the development of internal training on Denial and Appeals as determined by the internal and external quality reviews
- Aids legal counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in the appeals process
- Ensures Alliance staff are prepared for mediation and hearings by preparing and organizing all legal and clinical documents for 2nd level appeals
- Assists in the discovery process with Alliance’s legal department and draft Office of Administrative Hearings (OAH) documents
- Schedules mediation hearings and documents the process and outcomes
- Provide training and technical assistance to staff regarding Due Process rules
- Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definition and clinical guidelines when making appeal determinations
- Writes, edits, and/or coordinates the preparation of correspondence, reports, or other printed material according to well established standards or readily available
- Performs other related duties as assigned
Minimum Requirements
Education & Experience
A minimum of a Bachelor’s degree from accredited college or university with a major in mental health, public health, psychology, sociology, public administration, management information systems, statistics, or a related field. A minimum of two years working human services/behavioral health post bachelor’s degree and/or a minimum of two years of experience analyzing data sets, interpreting and synthesizing data into a report format, and working with teams/units to integrate data information needs.
Knowledge, Skills, & Abilities
- Knowledge of Federal and State regulations on Behavioral Healthcare grievances and appeals processes
- Knowledge on medical records practices and records keeping practices
- Knowledge of legal proceedings including mediation, administrative law courts, and other legal processes
- Demonstrated proficiency in personal computer use and MS Excel
- Some familiarity with other software packages, such as SPSS and MS Word, Project, Publisher, PowerPoint, and BI is desired
- Must have good oral, written, and graphic presentation skills
- Must demonstrate understanding of data analysis and techniques
- Demonstrated ability to learn new software and user capabilities
- Ability to integrate programmatic information into required data sets for analysis and interpretation
- Ability to work well with others in a fast-paced, and sometimes stressful, environment
- Experience with customer service, provider relations or similar activities is preferred
- Experience working with individuals with mental health, substance abuse issues, and/or intellectual disabilities preferred
Employment for this position is contingent upon a satisfactory background and credit check, which will be performed after acceptance of an offer of employment and prior to the employee's start date.
Salary Range
$61,439-$79,871/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
- Medical, Dental, Vision, Life, Long Term Disability
- Generous retirement savings plan
- Flexible work schedules including hybrid/remote options
- Paid time off including vacation, sick leave, holiday, management leave
- Dress flexibility
