Appeals & Grievances Analyst

Overview

UST Health Proof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world. Our brand is built on the foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

Appeals & Grievances Analyst —
Associate III - BPM

We are searching for a highly motivated Appeals & Grievances Analyst to join our team. The Appeals and Grievance Analyst is responsible for managing and resolving member and provider appeals and grievances in strict compliance with CMS regulations and organizational policies. This role ensures timely, accurate, and fully compliant case processing while upholding exceptional service standards and regulatory adherence.

• Review, analyze, and resolve member and provider appeals and grievances in accordance with CMS guidelines and Medicare Advantage requirements.
• Ensure compliance with federal and state regulations, organizational policies, and contractual obligations.
• Conduct detailed case investigations, gather supporting documentation, and prepare comprehensive case summaries.
• Communicate resolution outcomes to members, providers, and regulatory agencies in a clear and professional manner.
• Collaborate with internal departments (Claims, Utilization Management, Compliance) to ensure accurate and timely case handling.
• Monitor regulatory changes and assist in implementing process improvements to maintain compliance.
• Prepare reports and maintain accurate documentation for audits and regulatory submissions.

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

• High School Diploma required.
• Bachelor’s degree in business administration, Healthcare Management, or related field preferred.
• Minimum of 3 years of experience in a grievance and appeals environment, with strong knowledge of CMS regulations.
• Experience in medical benefits, claims processing, authorizations, and Medicare Advantage plans.
• Familiarity with Independent Review Entities (IREs) and CMS appeals/grievance processes.
• In-depth understanding of CMS regulations and Medicare Advantage requirements.
• Ability to review complex cases and apply regulatory standards accurately.
• Skilled in case management systems, claims platforms, and Microsoft Office Suite.
• Experience with HIPAA compliance and privacy regulations highly preferred.
• Skills &
  
  Competencies:
  
  Strong written and verbal communication skills for member/provider correspondence and regulatory reporting.
• Ability to identify issues, recommend solutions, and make sound decisions under strict timelines.
• Excellent time management and prioritization to handle multiple cases efficiently.
• Self-starter

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST Health Proof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role

Location:

Remote

Compensation Range: $40,000-$45,000

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits.

Regular employees may purchase additional…