Grievance and Appeal Quality AnalystPrimary Location: New Albany, OH
Additional Locations: OH-New Albany Apply
- Responsible for consistently auditing complaint and appeal cases, using complaint and appeal approved policies, workflows and manuals, for all resolution teams and products, in a database each month.
- All errors are applied using documented information.
- Will also complete coaching when errors/trends are identified.
- Consistently researches and audits complaints and appeals for all resolution teams each month.
- Investigate all data used in making audit determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
- Expert at researching standard plan design and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial. Can review a clinical determination and understand rationale for decision.
- Expert at researching various systems to verify accuracy of claim payment, member eligibility data, and billing/payment status.
- Expert letter writing skills, spelling, grammar, punctuation, inclusion of appropriate letter content, and appropriate state/federal regulatory language when required.
- Educates team mates as well as other areas on all components within the complaint and appeal area, for all products and services.
- Fairly evaluates rebuttals at the first level review, using documented workflows/policies.
- Identifies trends and emerging issues and reports on and gives input on potential solutions.
- Understands and can audit all resolution teams including, executive complaints and appeals, department of insurance, department of health, or attorney general and state complaints or appeals on behalf of members or providers.
- Exhibits behaviors outlined in the complaint & appeal quality policies.
- Experience in Medicaid and Medicare required
- 1-3 years experience in a complaint and appeal team preferred
- Including but not limited claim handling, products, compliance and regulatory analysis
- Experience in reading and researching benefit language and provider contracts, a plus
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
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