Appeals Analyst

Overview

• Analyze and resolve appeals, grievances, and coding disputes with confidentiality and adherence to regulatory guidelines.
• Interpret health plan benefits, policies, and medical terminology for members and providers.
• Exercise independent judgment to make decisions aligned with organizational policies.
• Prepare position statements for external reviews and benefit panels.
• Document investigations, findings, and actions in applicable systems.
• Ensure compliance with state and federal standards, accreditation agency requirements, and organizational policies.
• Collaborate with medical directors for clinical appeals and grievances.
• Monitor daily reports to maintain service timeliness and compliance.

Key Responsibilities & Duties

• Investigate and respond to appeals, grievances, and coding disputes from various stakeholders.
• Provide detailed responses that align with regulatory and accreditation guidelines.
• Analyze health plan benefits and policies to assist members and providers.
• Develop and present organizational positions for external reviews.
• Document findings and actions in organizational systems for transparency.
• Ensure compliance with applicable standards and organizational policies.
• Partner with medical directors for clinical decision-making.
• Monitor reports to ensure service quality and efficiency.

Job Requirements

• Bachelor’s degree or advanced degree preferred; alternatively, 5 years of related experience.
• Minimum of 3 years of relevant experience required.
• Certified Professional Coder certification required within one year for coding disputes.
• Proficiency in interpreting health plan benefits and policies.
• Strong analytical and decision-making skills.
• Experience with regulatory compliance and accreditation standards.
• Ability to document investigations and findings accurately.
• Effective collaboration with medical directors and external reviewers.