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.

ROLE RESPONSIBILITIES

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

PROFESSIONAL COMPETENCIES

• 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

WORK ENVIRONMENT

• 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.