Grievance and Appeals Analyst

Essential Duties:

The primary purpose of this job is to respond to written and/or verbal grievances, complaints and appeals submitted by members and providers in accordance with the regulations by NCQA, CMS, NY State and other entities.

 

· Provide written acknowledgment of all member and provider correspondence.

· Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.

· Interface with HIP’s departments, Delegated Entities, Medical Groups, and Network Physicians to ensure resolution of cases issues.  HIP Departments include, but not limited to: Claims, Customer Service, Enrollment and Billing, Legal, Marketing, Accounting, Provider Relations, Care Management, Mental Health, Pharmacy, Worker’s Compensation, Medicaid, CHIPS, Underwriting, and Medicare Product Management.  Delegated Entities include: Health Care Partners (HCP), Prism, Care Core National, Montefiore CMO, and Lenox Hill Health Care Network.

· Compose all type of correspondence related to processing of their cases.

· Prepare written responses to all member and provider correspondence.

· Monitor daily and weekly pending reports and personal SAWS worklist as well as make necessary follow-up calls to internal and external entities to ensure that cases are completed on or before the applicable timeframe.  Classify and code Feedback Tracking (FBT) inquiries appropriately, and enter all actions taken in investigation for the auditing and reporting purposes.

· Prepare a case narrative which includes the chronology of events for all completed files.

 

Knowledge Skills & Abilities:

· Judgment and common sense are crucial when determining response priorities (i.e., judge when issues should be forwarded to upper management for assistance), and to prioritize workload.

· Identify whether responses address the member/provider issues, and if not interact with respective entity to obtain corrected information.

· Prepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case.

 

Qualifications:

Bachelor’s degree with a minimum of two (2) years work experience in an HMO environment is required, or two (2) years of college with a minimum of four (4) years work experience.  Excellent oral and written communication skills required.  Strong organizational skills, accuracy and timely work required to meet position’s productivity requirements. Computer literate with proficiency in Microsoft Word required and desktop software knowledge preferred.