Appeals Analyst

Overview

• Analyze and resolve appeals, coding disputes, grievances, and coverage determinations following regulatory and accreditation guidelines.
• Interpret and explain health plan benefits, policies, and medical terminology to members and providers.
• Exercise independent judgment to make decisions based on established policies and guidelines.
• Prepare files and position statements for external reviews by independent organizations.
• Document investigations, findings, and actions in applicable systems to ensure compliance.
• Collaborate with Medical Directors for clinical appeals and grievances decisions.
• Ensure work quality and efficiency comply with state and federal accreditation standards.
• Monitor daily reports to maintain service timeliness and compliance.

Key Responsibilities & Duties

• Analyze and respond to appeals, grievances, and coding disputes from various stakeholders.
• Explain health plan benefits, policies, and procedures to members and providers.
• Develop position statements for external reviews and ensure regulatory compliance.
• Document investigation findings and actions in relevant systems.
• Monitor daily reports to ensure compliance with service standards.
• Collaborate with Medical Directors for clinical appeals and grievances decisions.
• Ensure adherence to state and federal accreditation standards.
• Maintain high-quality work output to meet performance guarantees.

Job Requirements

• Bachelor’s degree or equivalent experience required; advanced degree preferred.
• Minimum of 3 years of related experience; 5 years preferred.
• Certified Professional Coder certification required within 1 year for coding disputes.
• Strong understanding of health plan benefits, policies, and medical terminology.
• Proficiency in documenting investigations and findings in applicable systems.
• Ability to collaborate effectively with Medical Directors and other stakeholders.
• Knowledge of state and federal accreditation standards and guidelines.
• Experience in preparing position statements for external reviews.