GP Appeals Analyst I

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

📋 Description

• Oversee the complete process of handling complaints and appeals.

• Carry out investigations by collecting relevant documentation, interviewing key stakeholders, analyzing benefit, billing, and service-related issues, as well as reviewing calls, correspondence, and claims history.

• Create detailed appeal files containing claim records, authorizations, research summaries, Evidence of Coverage, medical records, timelines, exhibits, and other relevant Plan documents.

• Present cases to the Leadership Appeals Workgroup.

• Organize submissions to independent external reviewers and Administrative Law Judges when necessary.

• Compose clear written determinations and customer-friendly correspondence within stipulated turnaround times.

• Search for, listen to, and summarize all phone calls associated with cases.

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

• Provide testimony on behalf of the organization and participate in Administrative Law hearings as required.

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

• Conduct root cause analysis to identify trends, errors, and systemic issues.

• Suggest corrective actions and process enhancements.

• Work with various business areas to collect facts and comprehend benefit contracts.

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

• Keep meticulous tracking and documentation.

• Analyze trends to promote quality improvement and enhance the member experience.

• Undertake additional duties as assigned.

⛳️ Requirements

• High School Diploma/GED is mandatory.

• A Bachelor’s degree is preferred or relevant experience may substitute for a degree.

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

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

• Necessary experience in processing complex claims.

• 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.

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

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

• In-depth knowledge of Claims Policy guidelines is required.

• Strong proficiency in Microsoft Office Suite is essential.

• Keyboarding skills are required.

• Excellent language skills with the ability to communicate clearly and effectively.

• Strong quantitative reasoning and ability to perform accurate calculations.

• Ability to read and interpret complex written materials.

• Sound judgment in analytical or mathematical methods is necessary.

• Capability to analyze information and apply relevant rules, policies, and procedures.

• Professional business correspondence skills are essential.

• Ability to convey technical details in an accessible manner and prepare case-specific correspondence.

• Strong interpersonal skills, including active listening abilities.

• Proficient research, analytical, and problem-solving skills.

• Ability to manage multiple priorities effectively.

• Familiarity with de-escalation techniques for handling difficult or irate callers.

• Effective time-management skills are necessary.

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

• The employer may require applicants to pass assessments to determine minimum qualifications.

🏝️ Benefits

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

• Retirement Plans available.

• Generous Paid Time Off (PTO).

• Incentive Plans offered.

• Wellness Programs to support employee health.

• Paid Volunteer Time Off to encourage community involvement.

• Tuition Reimbursement to support ongoing education.

• Some travel may be required.