Appeals and Grievances Analyst
Associate III – BPM
Who we are:
Founded in 2016, we’ve become a trusted and valued partner for health plans and providers. We offer a modern integrated ecosystem of healthcare operations, processes, and products, with inherent scalability, efficiency, and predictable outcomes. Our BPaaS delivery solutions work behind the scenes to manage our customers’ complex admin operations, giving them elbow room to focus on their members’ needs and well-being.
Bending cost curves, guaranteeing outcomes, finding paths through roadblocks – that’s our way of life. Our customers count on us to safely navigate them through deadlocks. We have a strong global presence and a dedicated workforce of 4000+ people spread across the world.
Our brand is built on strong foundations of simplicity, honesty, and leadership, and we stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.
You Are:
UST HealthProof is searching for Appeals and Grievances Analysts, 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.
- Drive operational excellence into all processes and departmental interactions based on CMS and UST HealthProof’s requirements.
- 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. Relevant combination of education and experience may be considered in lieu of degree.
- Certification or progress toward certification is highly preferred and encouraged.
- 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.
- 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).
- Strong analytical, organizational, planning and problem-solving skills.
- Ability to effectively interface with employees at all levels.
- Ability to define problems, collect data, establish facts, and draw valid conclusions.
- 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.
Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by applicable law, UST Healthproof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.
Role Location: Remote
Compensation Range: $39,520-$43,680
Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits.
What We Believe
At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serves as a compass guiding every action and decision.
Guiding Principles
These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.
Integrity
Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.
People-Centricity
Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.
Simplicity
Simplifying complexity underlines everything we do - this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.
Leadership
Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.
Mission
A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.
#Healthproof
#CB
#LI-RJ1
#LI-Remote