Appeals Analyst

Overview

• Analyze and resolve appeals, grievances, and coding disputes in compliance with regulatory guidelines.
• Interpret health plan benefits, policies, and medical terminology for members and providers.
• Exercise independent judgment to make decisions ensuring business continuity.
• Prepare files and position statements for external reviews by independent organizations.
• Provide comprehensive responses to appeals and grievances adhering to accreditation guidelines.
• Document investigations, findings, and actions in applicable systems.
• Monitor daily reports to ensure service timeliness and compliance.
• Collaborate with Medical Directors for clinical appeals and grievances decisions.
• Ensure compliance with state and federal standards and organizational policies.

Key Responsibilities & Duties

• Analyze and respond to appeals, grievances, and coverage determinations from various stakeholders.
• Interpret and explain health plan benefits and policies to members and providers.
• Prepare documentation for external reviews and medical consultant evaluations.
• Provide detailed responses to appeals and grievances ensuring regulatory compliance.
• Document findings and actions in organizational systems.
• Monitor compliance with service timeliness and accreditation standards.
• Gather clinical information and collaborate with Medical Directors for appeals decisions.
• Ensure adherence to state and federal regulations and organizational policies.
• Maintain quality and efficiency in all work processes.

Job Requirements

• Bachelor’s degree or equivalent experience; advanced degree preferred.
• Minimum of 3 years of related experience; 5 years preferred.
• Certified Professional Coder certification required within 1 year for coding disputes.
• Proficiency in analyzing health plan benefits and medical terminology.
• Strong documentation and investigative skills.
• Ability to ensure compliance with state and federal standards.
• Experience in preparing files for external reviews and appeals.
• Effective collaboration with Medical Directors and regulatory agencies.
• Knowledge of accreditation agency standards and organizational policies.