Appeals & Grievance Analyst (Hybrid - Troy, MI) - Health Alliance Plan

GENERAL SUMMARY:

Responsible for the prompt and thorough investigation of medical and pharmacy member appeals and grievances for Health Alliance Plan’s (HAP’s): Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. Analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. The Analyst will work with HAP’s medical directors, nurses, pharmacists, Legal department, and other subject matter experts to determine appropriate outcomes for all cases. In addition, in this role the analyst will be required to keep abreast of regulatory requirements from State and Federal agencies and speak before members, senior leaders and other key stakeholders to present appeal cases on an ongoing basis. Provide verbal and written communication to members and providers on a daily basis. Ability to manage, organize and prioritize cases and complete within required timeframes. The analyst will also provide necessary support for audits and the development of desk level procedures.

 PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from: The Center for Medicaid and Medicare Services (CMS), MAXIMUS Federal Services, Department of Labor (DOL), Department of Insurance and Financial Services (DIFS), Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Office of Personnel Management (OPM), MI Health Link, and Better Business Bureau (BBB).
• Demonstrate strict adherence to the Centers for Medicare and Medicaid (CMS), MI Health Link (MMP), and Michigan Department of Health and Human Services (MDHHS) contracts in the responses to members, regulatory agencies, and providers.
• Provide concise and thorough written responses to members, regulatory agencies, and providers the findings of their investigations and resolution.
• Perform case pre-analysis; including procuring appropriate medical records and supporting documentation prior to sending case to internal stakeholders for subject matter expert reviews, working cross departmentally for resolution.
• Prepare cases for presentation during pertinent hearings (e.g. Administrative Law Judge hearings, MAXIMUS Committee Meetings, State Fair Hearings, Second-Level Member Hearings).
• Provide shadowing to new employees as part of their onboarding to the Appeal and Grievance Team.
• Perform other related duties as assigned.