Appeals & Grievance Analyst (Hybrid - Troy, MI)...
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GENERALSUMMARY: Responsible for the prompt and thorough investigation of medical and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. Analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. The Analyst will work with HAP's medical directors, nurses, pharmacists, Legal department, and other subject matter experts to determine appropriate outcomes for all cases. In addition, in this role the analyst will be required to keep abreast of regulatory requirements from State and Federal agencies and speak before members, senior leaders and other key stakeholders to present appeal cases on an ongoing basis. Provide verbal and written communication to members and providers on a daily basis. Ability to manage, organize and prioritize cases and complete within required timeframes. The analyst will also provide necessary support for audits and the development of desk level procedures. PRINCIPLEDUTIESANDRESPONSIBILITIES:
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GENERALSUMMARY: Responsible for the prompt and thorough investigation of medical and pharmacy member appeals and grievances for Health Alliance Plan's (HAP's): Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. Analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. The Analyst will work with HAP's medical directors, nurses, pharmacists, Legal department, and other subject matter experts to determine appropriate outcomes for all cases. In addition, in this role the analyst will be required to keep abreast of regulatory requirements from State and Federal agencies and speak before members, senior leaders and other key stakeholders to present appeal cases on an ongoing basis. Provide verbal and written communication to members and providers on a daily basis. Ability to manage, organize and prioritize cases and complete within required timeframes. The analyst will also provide necessary support for audits and the development of desk level procedures. PRINCIPLEDUTIESANDRESPONSIBILITIES:
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