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Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The Appeals and Grievances Analyst position will ensure that Bright Health responds to complaints, grievances, and appeals in a timely, professional, and customer-focused manner, and completed according to state and federal regulatory standards. This position will be responsible for resolution of assigned cases, accurate and timely documentation of case actions, and assist in the oversight of delegates responsible for appeals and grievances functions.
The Appeals and Grievances Analyst description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Reviews, researches, and directs complaints, grievances and appeal cases to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required timeframes are met, and proper written and verbal communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language. Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
- Maintains grievance and appeal case files and include necessary information to log incoming correspondences, tracking dispositions, and maintaining timeliness of resolution as required by state and federal mandates.
- Ensures that all information to members, providers, other parties-to-a-complaint, and other appropriate persons is accurate, consistent, and customer sensitive.
- Participates in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement.
- Communicates with internal and external partners as well as members and providers to ensure all required documentation is received to process the case.
- Monitor all incoming appeal and grievance channels including mail, fax and phone.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- Bachelor’s degree or equivalent work experience preferred
- Three (3) or more years of experience in health plan operations setting required, preferably in Appeals & Grievances or Claims
- Two (2) or more years of Medicare Advantage experience preferred
- Detail oriented
- Thrive in fast-paced environments and have a passion for extemporary customer service and resolving conflicts
- Self-directed, able to prioritize and takes ownership in projects, cases, and workgroups
- The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.