Appeals Analyst

Appeals Analyst Overview

• The Appeals Analyst role involves analyzing and resolving appeals, coding disputes, and grievances with adherence to regulatory guidelines.
• Interpret and explain health plan benefits, policies, and medical terminology to members and providers.
• Utilize judgment to make decisions aligned with organizational policies and ensure business continuity.
• Prepare documentation and position statements for external reviews and consultations.
• Monitor daily reports to ensure compliance and service timeliness.
• Collaborate with Medical Directors for clinical appeals and grievances decisions.
• Ensure work quality and efficiency to meet accreditation standards and organizational policies.
• Document investigations, findings, and actions in applicable systems comprehensively.

Appeals Analyst Key Responsibilities & Duties

• Analyze and resolve appeals, grievances, and coding disputes from various stakeholders.
• Interpret health plan benefits and policies for members and providers.
• Prepare documentation for external reviews and benefit panels.
• Monitor compliance and service timeliness through daily reporting.
• Collaborate with Medical Directors for clinical information gathering and decisions.
• Ensure adherence to state and federal accreditation standards.
• Document investigation findings and actions in organizational systems.
• Act decisively to maintain business continuity and compliance.

Appeals Analyst Job Requirements

• Bachelor’s degree required; in lieu of degree, 5 years of related experience.
• Minimum of 3 years of related experience; 5 years preferred.
• Certified Professional Coder certification required within 1 year for coding disputes.
• Strong knowledge of regulatory and accreditation guidelines (CMS, ERISA, NCQA).
• Proficiency in medical terminology and health plan policies.
• Ability to document findings and actions comprehensively in organizational systems.
• Excellent analytical and decision-making skills.
• Familiarity with appeals, grievances, and coding dispute resolution processes.