Grievance & Appeals Analyst (Full time Remote, North Carolina Based)

$52,000 - $67,600/Yr

Alliance Healthcare - Morrisville, NC

Full-time - Entry Level

Morrisville, NC

Ambulatory Health Care Services

About the position

The Grievance and Appeals Analyst is responsible for managing grievances and appeals to ensure compliance with organizational policies, state and federal guidelines, and due process rights. The role involves synthesizing and analyzing data, coordinating responses from various business units, and providing timely, customer-focused resolutions to complaints. The Analyst will work remotely and must be a resident of North Carolina, with no routine office presence required.

Responsibilities

• Receive and monitor information related to provider quality assurance issues, including grievances and appeals.
• Ensure comprehensive quality assurance information is available to agency staff and departments as needed.
• Identify trends within grievance, appeal, and clinical data sources using critical thinking.
• Mediate complex relationships between external and internal stakeholders to achieve satisfactory resolutions.
• Ensure compliance of resolutions with local, state, and federal regulations regarding member experiences.
• Utilize internal and external data platforms for thorough analysis of member experience issues.
• Provide information to stakeholders verbally and in writing using professional communication skills.
• Monitor timelines for quality assurance issues and reports to ensure timely reviews.
• Define recommendations and improve practices based on analytical skills.
• Create and present analyses of short-term studies to management and staff.
• Train internal and external customers on quality assurance reporting requirements.
• Review policies and procedures, recommending changes in alignment with current guidelines.
• Prepare and ensure timely mailing of appeal and outcome notification letters.
• Track appeal requests and manage the local reconsideration review process.
• Maintain accessible denial and appeals files.
• Participate in internal training development on Denial and Appeals processes.
• Assist legal counsel in communication and document exchange during appeals.
• Prepare Alliance staff for mediation and hearings by organizing legal and clinical documents.
• Assist in the discovery process with the legal department and draft OAH documents.
• Schedule mediation hearings and document processes and outcomes.
• Provide training and technical assistance regarding Due Process rules.
• Review first level appeal decisions for compliance with service definitions and clinical guidelines.
• Write, edit, and coordinate correspondence and reports according to established standards.

Requirements

• Bachelor's degree in mental health, public health, psychology, sociology, public administration, management information systems, statistics, or a related field.
• Minimum of two years working in human services/behavioral health post-bachelor's degree or two years of experience analyzing data sets and synthesizing data into reports.

Nice-to-haves

• Experience with customer service, provider relations, or similar activities.
• Experience working with individuals with mental health, substance abuse issues, and/or intellectual disabilities.

Benefits

• Medical, Dental, Vision, Life, Long Term Disability insurance.
• Generous retirement savings plan.
• Flexible work schedules including hybrid/remote options.
• Paid time off including vacation, sick leave, holiday, and management leave.
• Dress flexibility.