Point32Health - Canton, MA
posted about 2 months ago
Full-time - Entry Level
Canton, MA
Insurance Carriers and Related Activities
About the position
The Member Appeals and Grievance Analyst is responsible for managing and coordinating member appeals and grievances in compliance with State and Federal regulations. This role involves working collaboratively with members and their representatives, demonstrating superior customer service, and preparing cases for review by the Member Appeals Committee. The Analyst must efficiently handle multiple functions, prioritize tasks, and ensure compliance with regulatory requirements while advocating for members' needs.
Responsibilities
- Act as a member advocate, clearly communicating the appeal and grievance process both orally and in writing.
- Manage assigned member appeals and grievance cases from documentation to investigation and resolution, ensuring compliance with regulatory requirements.
- Review and interpret product and benefit designs according to State and Federal regulations.
- Manage the collection of necessary documents and records for researching appeals or complaints.
- Consult with subject matter experts to gather information for appropriate resolution of matters presented.
- Make recommendations on appeal decisions based on member benefits and individual circumstances.
Requirements
- Associate's Degree or equivalent experience in health care, conflict resolution, or related field.
- 3-5 years of health care or insurance experience.
- Health care benefit and regulatory knowledge preferred.
- Knowledge of insurance products, policies, and procedures preferred.
- Demonstrated proficiency in operating a computer and related equipment, including Windows applications.
Nice-to-haves
- Experience in conflict resolution or customer service in a healthcare setting.
- Familiarity with NCQA, DOI, CMS, DOL regulations.
Benefits
- Medical, dental, and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
