Appeals and Grievance Analyst

Who We Are

Point
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Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
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Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We’ve had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it’s at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point
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Health.

Under the general direction of the Member Appeals and Grievance Supervisor the Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point
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Health. This individual works collaboratively with the member and/or the member’s authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member’s appeal or grievance providing further appeal options as appropriate.

Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. The employee must have the ability to learn and apply Point
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Health’s policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point
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Health members for all lines of business.

• Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member’s appeal or grievance is compliant with the regulatory requirements set‑forth by NCQA (National Committee for Quality Assurance), DOI (Dept of Insurance), CMS, DOL and any state or federal specific regulations that apply.
• Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements.
• Manage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customers.
• Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
• Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
• Perform other duties and projects as assigned.

• Required (minimum):
  Associate’s Degree or equivalent experience in health care, conflict resolution or related field
• Preferred:
  Bachelors Degree in related field

• Required (minimum): 2-4 years' experience as a customer service or member services representative in…