Grievance and Appeals Analyst I
$45,760–$49,920 year
On-site · Doral, Florida, United States
Job Summary
Grievance and Appeals Analyst I responsible for reviewing, investigating, and resolving member grievances and appeals within CMS/NCQA guidelines in a managed-care health plan. Conducts comprehensive review of grievances, appeals, and complaints; analyzes claims, benefits, authorizations, and supporting documentation; ensures timely processing within regulatory timelines; reviews medical records and provider documentation; applies contract language and coverage policies; collaborates with Medical Management, Provider Relations, and Compliance to ensure accurate resolutions; identifies root causes of issues in claims processing and system configuration; prepares compliant written correspondence to members and providers; documents all case activity for audits and regulatory compliance; tracks trends for quality improvement; communicates with members and providers to obtain additional information as needed; meets departmental productivity and quality standards.
Required Qualifications
- Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing; or equivalent combination of education and experience
- Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances
- Understanding of NCQA standards related to member complaint and appeals processes
- Experience reviewing claims, including eligibility, coordination of benefits (COB), and denial management
- Strong analytical and problem-solving skills with attention to detail
- Excellent written and verbal communication skills, with the ability to compose regulatory-compliant correspondence
- Strong organizational and time management skills with the ability to manage multiple priorities and meet strict deadlines
- Proficiency in Microsoft Office applications and relevant claims or case management systems
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