Senior Appeals & Grievances Analyst

Under general direction of the Supervisor of Member Appeals and Grievances, the primary function of the Sr. Analyst is to ensure the Appeals and Grievance team delivers timely, thorough and accurate case information to members, providers and other external constituents.

This individual will provide technical support, direction and guidance to ensure staff deliver best in class service and resolution of Appeals and Grievances that meets and exceeds customer expectations.

In addition to a standard case-load, this individual assists in assigning and prioritizing team and individual caseloads. Responsibilities include ensuring day to day operational activities are compliant with all regulatory and departmental operational metrics, participating in the onboard of new hires as well as focused day to day support for team members.

Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment.

The employee must have the ability to learn and apply Point32Health policies as well as State and Federal regulations consistently and seek out guidance as needed. The Sr Appeals and Grievance Analyst will participate in weekend and holiday on call as scheduled therefore will be cross trained on the various lines of business.

Key Responsibilities/Duties – what you will be doing

Manage assigned member appeals and formal complaint cases from documentation through resolution

Coach, develop, and mentor staff in the accurate and timely management of Appeals and Grievances providing on-the-spot technical support and direction.

Ensure timely communication with Supervisor on any issues having the potential to impact operation or organization.

Maintain an up-to-date working knowledge of policies, products, procedures, benefits, claims, state regulatory requirements and mandates, federal mandates, network/site issues.

Ensures delivery of optimal customer services by working cross functionally with internal business units and external stakeholders, including physicians, attorneys, and elected officials

Other duties as assigned

Qualifications – what you need to perform the job

Ability to interact with all levels of personnel, along with knowledge of principles and practices of effective supervision

Effective decision-making abilities, strong communication, and organizational skills.

Ability to prioritize time and resources, as well as ability to identify staff needs.

Complaint resolution and negotiation skills preferred.

Working knowledge and training in effective customer service techniques. Active listening and observation skills required. Proven ability to provide outstanding customer service

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts.

Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Talent

Boost is now Ignyte AI.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID:

R6715