Member Appeals & Grievance Analyst – Level 2

This is a fully remote position, open to applicants in Tennessee.

📋 Description

• Investigate and document the details of appeals, grievances, or complaints, including actions taken regarding clinical care or reimbursement matters.

• Inform all relevant parties of the outcomes of reviews, whether appeals, grievances, or complaints are approved or denied.

• Communicate resolutions for CMS complaints to CMS and members/appellants within the required regulatory timelines.

• Deliver outstanding customer service to members, providers, and CMS.

• Stay informed about and comply with CMS regulations and guidelines that pertain to the appeal, grievance, and complaint processes.

• Assess cases, identify suitable next steps, and handle multiple priorities while adhering to turnaround times.

• Responsibly utilize digital and AI-enhanced tools to enhance workflow efficiency.

⛳️ Requirements

• An associate's degree or equivalent work experience is required.

• A minimum of 2 years of customer service and/or claims experience.

• Familiarity with Medicare and CMS regulations and guidelines relevant to appeals, grievances, and complaints.

• Proficient in Microsoft Office applications, including Outlook, Word, Excel, and PowerPoint.

• Strong oral and written communication abilities.

• Excellent interpersonal and organizational skills.

• Capability to work independently with minimal supervision and collaboratively in a high-paced environment.

• Problem-solving skills and the ability to manage multiple assignments with stringent deadlines.

• Ability to analyze claims, medical records, and documents relevant to case reviews.

• Strong analytical capabilities and keen attention to detail.

• High accuracy in data entry and case management skills.

• A customer-centric mindset.

• Experience with or a keen interest in utilizing AI tools such as Copilot.

• Required to cover weekends every week.

• Commitment to remain in the weekend role for at least 2 years following the completion of all training.

• Sponsorship is not available for this position.

• Remote positions are not available to applicants located in California, Massachusetts, New Hampshire, New Jersey, or New York.

🏝️ Benefits

• Fully remote work arrangement.

• 40-hour work week.

• Flexibility based on business requirements.

• Remote-first organizational culture.

• Potential relocation assistance if residency in Chattanooga, TN is necessary and eligibility conditions apply.