Appeals and Grievance Analyst

Who We Are

Point32Health is a leading health and wellbeing organization delivering an everbetter personalized health care experience to everyone in our communities. At Point32Health we are building on the quality nonprofit heritage of our founding organizations Tufts Health Plan and Harvard Pilgrim Health Care where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members partners colleagues and communities.

Job Summary

Under the general direction of the Member Appeals and Grievance Supervisor the Member Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual works collaboratively with the member and/or the members authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation discussion review and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the members appeal or grievance providing further appeal options as appropriate. Analysts routinely interact with members providers and other internal and external constituents about highly escalated issues.

Essential functions will occur simultaneously; therefore the employee must be able to appropriately handle each of these functions prioritize them and seek assistance when necessary. The employee must have the ability to learn and apply Point32Healths policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for all lines of business.

Job Description

• Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation to investigation and through resolution ensuring the final disposition of a members appeal or grievance is compliant with the regulatory requirements setforth by NCQA DOI CMS DOL and any state or federal specific regulations that apply.
• Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements
• Manage the collection of documents and records (medical claims administrative) needed to fully research the appeal or complaint request with both internal and external customers
• Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
• Make recommendations on appeal decisions based on the members benefits and individual circumstances presented.

• Associates Degree or equivalent experience in health care conflict resolution or related field
• 35 years health care or insurance experience
• Health care benefit and regulatory knowledge preferred
• Demonstrated proficiency in operating a computer and related equipment including knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.
• Must possess initiative balanced judgment objectivity and the ability to independently plan and prioritize ones own work to assure maximum efficiency and compliance.
• Must be able to organize plan and implement the functions of Member Appeals and Grievances maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws
• Demonstrated ability to synthesize and process complex information and deliver the information both verbally and written in a clear concise and articulate manner. Requires strong verbal and written skills to effectively communicate at both detail and summary levels to a variety of constituents.
• Requires excellent interpersonal skills in order to communicate and work with multiple constituents.
• Requires ability to understand and be compliant with State and Federal regulations.
• Superior investigation analytical and problemsolving skills
• Excellent customer service and interpersonal skills
• Working knowledge of plan products and benefits and the ability to communicate this information to members providers employers and external agencies clearly and concisely.
• Ability to work independently and collaborate as part of a team

Working Conditions and Additional Requirements

• Weekend Coverage may be required on a rotating basis as regulated for line of business.
• May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

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