Appeal & Grievance Ops Analyst (Hybrid - Troy/MI) - Health Alliance Plan

GENERAL SUMMARY:

This position is responsible for receiving, analyzing, and assigning Appeals, Grievances and Complaints (A&G) to the A&G Analysts. Responsible for all activities related to maintaining and providing pertinent information for the purpose of regulatory reporting ensuring integrity and accuracy. Assisting the A&G staff with administrative duties, statistical data on the activity of Appeals, Reconsideration, Redeterminations and Grievances, which will identify trends and opportunities to proactively address member concerns and improve the customer experience.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Ensures daily case receipt via mail, fax, email, Customer Message Center and HAP’s documentation application Pega (Customer Services Specialists), and vendor sites.  Responsible for investigation, assignment and tracking for Appeals, Reconsiderations, Redeterminations, and Grievances and entry into care management system. Ensures adherence to CMS, NCQA, and DOL regulatory and compliance guidelines.

• Assists Appeal and Grievance Analyst in providing case data to support all internal and external reporting. Maintains the Access database as the source for departmental information to support Data Validation, NCQA, Medicare 5 Star, MARS and other initiatives.

• Responsible for providing all case documentation for External Review requests by DIFS, OPM, MAXIMUS, etc.

• Works with leadership to create and update Correspondences for Medicare Advantage and Commercial members and providers while ensuring compliance with regulatory entities.

• Works with Client Services Training department to create and maintain updated documents and desk level procedures to ensure new and current staff have resources available for continuing education.

• Provides administrative support to the Appeal and Grievance Manager and the Appeal and Grievance Analyst. Maintains professionalism and confidentiality and orders departmental supplies. Organizes and oversees the annual case purge performed by the Clerical team.

• Ensures meetings are scheduled as required and proper materials are prepared, distributed and presented as all meetings including but not limited to departmental, Grievance Pre Hearing and Grievance Committee Hearings.

• Performs record and document searches, collection and submission for the Legal Department.

• Creates statistical weekly, monthly and annual reports for Appeals and Grievances activity providing rationale when the activities are skewed; compile annual reporting data using charts and MS Power Point for distribution to internal leadership.

• Establishes and maintain strong relationships and contacts across departments in addition to external contacts to ensure open communication, team effort and positive work relations. Continues to self-educate on changes in policies and procedures that occur in other departments that could have an impact on the Appeal and Grievance department operations and the servicing of member/customers.

• Performs other related duties as assigned.