GP Appeals Analyst I

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 into member/provider complaints and appeals by collecting documentation, interviewing relevant parties, analyzing benefit, billing, and service issues, and reviewing calls, correspondence, and claims history.

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

• Manage submissions to independent external reviewers and Administrative Law Judges as necessary.

• Provide clear explanations regarding denial decisions, benefit coverage, and case management.

• Utilize critical thinking and root-cause analysis to draw conclusions and suggest resolutions or corrective measures.

• Compose precise, professional, and customer-friendly written determinations and correspondence within specified turnaround times.

• Search, assess, and summarize phone conversations linked to cases.

• Collaborate with Legal, Compliance, and Regulatory Affairs on escalated cases and may represent the organization in testimony.

• Validate medical claims based on Evidence of Coverage or State Medicaid contracts, benefit configurations, and coding.

• Recognize trends, errors, and systemic issues while proposing process enhancements.

• Work with various business areas to gather information and comprehend applicable benefit contracts.

• Approve administrative exceptions, including higher-threshold claim adjustments.

• Present cases to the Leadership Appeals Workgroup and participate in Administrative Law hearings.

• Maintain meticulous case tracking and documentation.

• Carry out additional duties as assigned.

⛳️ Requirements

• High School Diploma/GED is mandatory.

• Bachelor’s degree is preferred or relevant experience may be accepted in lieu of a degree.

• Minimum of four years of experience in correspondence and/or telephone customer service focused on screening, investigating, and addressing inquiries.

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

• Necessary expertise in complex claims processing.

• Prior experience 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.

• Required understanding of medical terminology, COB, and Medicare procedures.

• Knowledge of Medicare/Medicaid regulations and guidelines is required.

• Extensive knowledge of Claims Policy guidelines is necessary.

• Proficiency in Microsoft Office Suite is required.

• Keyboarding skills are essential.

• Strong language proficiency and effective communication skills.

• Capability in quantitative reasoning and interpreting numerical data.

• Ability to read and understand complex written materials.

• Skills in analysis, mathematics, research, problem-solving, and sound judgment.

• Ability to create professional business correspondence that clearly conveys complex information.

• Strong interpersonal abilities, including active listening.

• Effectively manage multiple priorities.

• De-escalation skills for handling challenging or upset callers.

• Proficient time-management abilities.

• Candidates may need to pass employment qualification tests.

• Employees must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.

• Remote work arrangements.

• Some travel may be necessary.