Appeals Analyst

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Oversee the complete lifecycle of complaint and appeal cases.

• Conduct thorough investigations by collecting documentation, interviewing relevant stakeholders, and reviewing calls, correspondence, and claims history.

• Compile detailed appeal files for the Leadership Appeals Workgroup, independent external reviewers, Administrative Law Judges, CMS, and State entities.

• Present cases to leadership and participate in Administrative Law hearings, collaborating with Legal as required.

• Draft written determinations, correspondence, denial explanations, and case-specific communications within mandated turnaround times.

• Verify medical claims against the Evidence of Coverage or State Medicaid contracts, ensuring proper benefit configuration and coding.

• Liaise with internal and external stakeholders, various business areas, State agencies, and Departments of Banking and Insurance.

• Consult with Legal, Compliance, and Regulatory Affairs on escalated cases.

• Conduct root-cause analysis, identify trends and systemic issues, and propose corrective actions and process enhancements.

• Authorize administrative exceptions, including adjustments to higher-threshold claims.

• Maintain meticulous tracking and documentation, analyzing trends to enhance quality and member experience.

• Perform additional duties as assigned.

⛳️ Requirements

• High School Diploma or GED is mandatory.

• A Bachelor’s degree is preferred, or relevant experience may be considered in place of a degree.

• Minimum of four years of customer service experience in correspondence and/or telephone inquiries, including screening, investigating, and examining cases.

• Preferred experience in health insurance, specifically with claim appeals and grievances.

• Necessary experience in complex claims processing.

• Prior experience in handling grievances and appeals is preferred.

• Required knowledge of insurance claim and membership systems.

• Familiarity with claim processes, benefits, and claim policy guidelines is essential.

• Knowledge of medical terminology, COB, and Medicare procedures is required.

• Understanding of Medicare/Medicaid regulations and guidelines is essential.

• Comprehensive knowledge of Claims Policy guidelines is required.

• Proficiency in Microsoft Office Suite is essential.

• Keyboarding skills are necessary.

• Strong language skills with clear and effective communication abilities.

• Capable of quantitative reasoning and interpreting numerical data.

• Ability to read and understand complex written materials.

• Possess analytical, mathematical, research, problem-solving, interpersonal, de-escalation, and time-management skills.

• Ability to effectively manage multiple priorities.

• Some travel may be necessary.

🏝️ Benefits

• Comprehensive health benefits including Medical, Dental, and Vision.

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.