Gateway Health Plan
Job Description :
I. GENERAL OVERVIEW:
The Appeals Analyst reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.
II. ESSENTIAL RESPONSIBILITIES:
1. Review inquiries to determine if they meet definition of appeal/grievance.
2. Request and review all related relevant documentation and assemble case file.
3. Coordinate resolution results and relay investigative results with all involved parties.
4. Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
5. May support the Quality Assurance, Appeal and other quality committees.
6. Other duties as assigned or requested.
Education, Licenses/Certifications, and Experience
- 3-5 years of relevant, progressive experience in the area of specialization.
- A High School Diploma or GED is required for all levels
- Experience in Customer Service or a related field
Knowledge, Skills and Abilities
- Knowledge of multiple processing systems and workflows
- Knowledge of claims processing methodologies
- Ability to interpret all government regulations
- Knowledge of company products
- Excellent organizational skills
- Strong verbal and written communication skills
IV. SCOPE OF RESPONSIBILITY:
Does this role supervise/manage other employees?
V. WORK ENVIRONMENT
Is Travel Required?
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