Appeals and Grievance Analyst

🔥 19 hours ago

🇺🇸 United States – Remote

💵 $20 - $25 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

⚕️ Healthcare Insurance

☁️ SaaS

💳 Fintech

Healthcare Insurance • SaaS • Fintech

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• 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. • 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.

🎯 Requirements

• Bachelor’s degree in Business Administration, Economics, Health Care, Information Systems, Statistics or other related field is required • Certification or progress toward certification is highly preferred and encouraged. • Five years experience in a grievance and appeals environment • 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 • Strong knowledge and use of existing software packages (PowerPoint, Excel, Word, etc) • Working knowledge of data languages such as SAS or SQL • Ability to effectively interface with employees at all levels.

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible work hours • Paid time off • Remote work options