Appeals and Grievance Analyst

Who We Are:

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

You Are:

The Appeals and Grievance Analyst, acting in a quality assurance capacity, is responsible for the 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.

The Opportunity:

• 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.
• 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.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

What You Need:

• 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.
• Certification or progress toward certification is highly preferred and encouraged.
• EXPERIENCE: Five years 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.
• Experience in legal research and monitoring of federal and state regulatory laws and legislations preferred.
• 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 knowledge and use of existing software packages (PowerPoint, Excel, Word, etc).
• Working knowledge of data languages such as SAS or SQL.
• Strong analytical, organizational, planning and problem solving skills.
• Ability to effectively interface with employees at all levels.
• Understand and apply statistical inference.
• Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
• Ability to write reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
• 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 exceed deadlines.

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

FLSA Classification (USA Only): Exempt 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:  

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

#LI-Remote 

**The annual US base salary range for this position is $20 - $25/hr. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.