Johns Creek (USA)
Posted 60 days ago
The Grievance and Appeals Analyst is responsible for reviewing correspondence from covered persons, employers, providers or agents requesting to file a grievance/appeal and coordinating a response to the appellant in compliance with all state and federal requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Researches and resolves all appeals and any correspondence in clear and concise written form, maintaining compliance with state and federal time frames and requirements
- Will work closely with internal and Carrier Compliance Departments on grievance and appeal related activity
- Independently assess, investigates and resolves difficult issues to achieve appellant satisfaction by utilizing company and industry knowledge of operational areas and all established policies and procedures.
- Will work closely with our Clinical Director and if necessary, will utilize our external vendors to assure that the appropriate medical decisions are made.
- Track appeals in the access data base to ensure specific turnaround time for responses and provide data for state required or requested reports.
- Gather, compile and Produces monthly/quarterly reports on the grievance and appeals process for carriers and management including, but not limited to, number of appeals by categories, number of denials upheld and adjusted and timeframes met.
- Provide feedback to service teams and management in an effort to educate and reduce overall appeal volume.
- Prepare and present appeal cases to Review Committee
- Performs similar job-related duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Associate's degree (A. A.) or equivalent from two-year college or technical school;
- 3 – 5 years related experience and/or training; or equivalent combination of education and experience.
- Detailed oriented with strong analytical skills.
- Excellent organizational skills.
- Effective verbal and written communication skills.
- Working knowledge of claims and plan/policies.
- Strong PC skills.
- Working knowledge of medical terminology.
- Ability to work independently in a fasted paced environment.