Member Appeal Analyst

Responsible for complex and thorough investigation of appeals external complaints and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line gather all relevant information for the appeal request (external medical records internal documentation from enterprise-wide systems including: claims payments billing and enrollment care management medical pharmacy and behavioral health authorizations customer service interactions prescription claims medical policies and plan documents).
Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently determine if pharmacy and medical policies have been applied appropriately or if additional clinical information is available after the original decision

Support root cause analysis to determine corrective actions related to the appeals process by researching system issues to determine course corrections

Apply strong analytical skills and business knowledge to investigation analysis and recommendation of solutions to problems
Communicates collaborates and acts as a consultant to internal and external customers in order to resolve complex issues

Resolve appeal requests prior to committee or fair hearing review when appropriate including collaboration internally with all levels within the organization including Executives Market Segment Leaders Medical Directors Legal Medical Operations Enterprise Operations Customer Service and leaders throughout the organization and externally with providers agents members and employer groups.

If not resolved prior to the Appeal Committee process prepare the presentation of all relevant facts and present concise yet comprehensive information to the appropriate committee(s) to ensure a full and fair review;
Coordinate and manage reviews with Independent Review Organizations (IRO) when appropriate; work with Medical Directors to suggest and solicit appropriate questions for IRO response. Ensure all required documentation and files are complete organized and secure to meet State Federal Health Plan and NCQA requirements.
Effectuate Appeal committee DIFs CMS and other regulatory body directed decisions and ensure outcomes are effectively communicated (oral and written) following CMS NCQA and other applicable guidelines.

Support the lead for expedited requests gathering relevant information working with Medical Director to determine if criteria is met. If expedited criteria is met ensure investigation review decision and completion within required 72 hour time line. Communicate outcome to member.

Provide education and communicates training needs to Customer Service Leadership when appropriate to avoid unnecessary appeals and/or expedited requests.

Track all activity including communication for each appeal case by entering complete documentation of issues and related follow-up ensuring all customers receive required correspondence according to time line requirements and to ensure all regulatory reporting requirements are met.

Collaborate with cross-functional departments to implement improvements to member experience medical policies legal documents member materials departmental processes and workflow.