Appeals Analyst

Overview

• Analyze and resolve appeals, coding disputes, grievances, and coverage determinations with adherence to regulatory guidelines.
• Interpret and explain health plan benefits, policies, procedures, and medical terminology to members and providers.
• Exercise independent judgment to make decisions aligned with policies and guidelines.
• Prepare files and position statements for external reviews by independent organizations and consultants.
• Provide comprehensive responses to appeals and grievances ensuring compliance with regulatory standards.
• Document investigations, findings, and actions in applicable systems.
• Monitor daily reports to ensure timely service and compliance with standards.
• Collaborate with Medical Directors for clinical appeals and grievances decisions.
• Ensure work quality and efficiency meet mandated state and federal accreditation standards.

Key Responsibilities & Duties

• Conduct thorough research and analysis to resolve appeals and grievances.
• Explain complex health plan benefits and medical coding to stakeholders.
• Prepare detailed documentation for external reviews and regulatory compliance.
• Ensure timely and accurate responses to inquiries and disputes.
• Maintain compliance with state and federal regulations in all activities.
• Collaborate with internal teams to ensure alignment with organizational policies.
• Monitor and report on service metrics to ensure performance guarantees are met.
• Utilize corporate medical policies to gather clinical information for appeals.
• Support decision-making processes with comprehensive investigative findings.

Job Requirements

• Bachelor’s degree or advanced degree; alternatively, 5 years of related experience.
• Minimum of 3 years of relevant experience in appeals, grievances, or coding disputes.
• Certified Professional Coder certification required within one year of employment.
• Proficiency in interpreting health plan benefits, medical terminology, and coding.
• Strong analytical and decision-making skills to handle sensitive cases.
• Knowledge of state and federal regulatory standards (CMS, ERISA, NCQA).
• Experience with documentation and compliance systems for appeals processing.
• Ability to work remotely and manage tasks independently.
• Excellent communication skills for interaction with diverse stakeholders.