Address
Form of work
SalaryStefanini Group is hiring!
Stefanini is looking for a Grievance/Appeal Analyst for Remote location.
For quick apply, please reach out to Rahul Kumar; Phone: 248.936.5060/ Email: Rahul.kumar@stefanini.com
Open to W2 Candidates Only!
Description:
- 100% Remote
- Client Equipment to be provided.
- Effectively administer all steps of the grievance and review processes for Priority Health non-Medicare products in a pleasant and expedient manner to ensure quality customer service and compliance with all legislative, regulatory and accreditation requirements.
- Assist customers throughout the process by providing complete information and follow up on a timely basis.
- Ensure committee, State and Federal decisions are properly implemented.
Job Summary:
- Responsible for the analysis, research and completion of complex member grievance investigations.
- Effectively administer all steps of the member grievance.
- Thoroughly investigate member grievances, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible.
- Ensure compliance with all mandated, legislative, regulatory and accreditation requirements.
- Assist members and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented.
- Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements.
- Prepares and presents education to internal departments. Serves as a mentor/trainer to other team members.
- The Grievance Analyst makes decisions on moderately complex issues regarding technical approach for project components, and work is performed without direction. Exercises latitude in determining objectives and approaches to assignments.
- Remote work for this position may be approved based on policy and business considerations.
Essential Functions:
- Responsible for complex and thorough investigation of grievances, external complaints, and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the grievance captured (internal documentation from enterprise-wide systems including: claims payments, billing and enrollment, care management, medical, pharmacy and behavioral health authorizations, customer service interactions, prescription claims, medical policies, and plan documents).
- Evaluate information gathered to ensure all benefit language outlined in plan documents have been interpreted accurately and consistently.
- Track all activity including communication for each grievance by entering complete documentation of issues and related follow-up, ensuring all customers receive required correspondence according to timeline requirements and to ensure all regulatory reporting requirements are met.
- Conducts root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course corrections
- Perform quality assurance reviews for case files, decision forms, documentation, and logs to ensure they are complete, organized, and secure and ensure all procedures are followed and timeline requirements are met, including implementation of all Committee, and State or Federal decisions.
- Provide technical, product, policy and procedure education and training for new and existing staff. Provide education and communicates training needs to Customer Service Leadership, when appropriate, to avoid unnecessary appeals and/or expedited requests.
- Collaborate with cross-functional departments to implement improvements to member experience, medical policies, legal documents, member materials, departmental processes, and workflow.
- Conducts root cause analysis to determine corrective actions related to the grievance process by researching systemic issues to determine course corrections
- Apply strong analytical skills and business knowledge to investigation, analysis and recommendation of solution Communicates, collaborates, and acts as a consultant to internal and external customers in order to resolve complex issues.
Qualifications:
- Required Associate's Degree or equivalent
- Preferred Bachelor's Degree or equivalent
- 5 years of relevant experience Grievance & or Appeal Analyst or related experience Required
- 3 years of relevant experience Member or Provider Customer service, Claims, Legal and/or enrollment/eligibility Preferred
- Working knowledge of Priority Health systems for claims payment, care management, authorizations, customer service interactions, pharmacy, Rx profiles, medical policies, and plan documents for all non-Medicare product lines (Commercial Group, Commercial individual, PH Insurance Company (PHIC), Self-funded, Government Programs – Medicaid) Preferred
- Extensive knowledge of managed care products and regulatory and accreditation requirements; Maintain knowledge of policies and procedures, including medical policies which may impact the grievance, appeal and review processes Preferred
***Listed salary ranges may vary based on experience, qualifications, and local market. Also, some positions may include bonuses or other incentives***
Stefanini takes pride in hiring top talent and developing relationships with our future employees. Our talent acquisition teams will never make an offer of employment without having a phone conversation with you. Those face-to-face conversations will involve a description of the job for which you have applied. We also speak with you about the process including interviews and job offers.
About Stefanini Group:
The Stefanini Group is a global provider of offshore, onshore and near shore outsourcing, IT digital consulting, systems integration, application, and strategic staffing services to Fortune 1000 enterprises around the world. Our presence is in countries like the Americas, Europe, Africa, and Asia, and more than four hundred clients across a broad spectrum of markets, including financial services, manufacturing, telecommunications, chemical services, technology, public sector, and utilities. Stefanini is a CMM level 5, IT consulting company with a global presence. We are CMM Level 5 company.
