Senior Grievances & Appeals Analyst

Responsibilities

• Analyze and audit complaints received by the plan to ensure the integrity of claims, authorization processes, and business operations.
• Utilize established process guidelines and industry knowledge to validate organizational decisions and assess downstream and upstream impacts.
• Perform root cause analysis of audit findings and make recommendations for appropriate change management.
• Emphasize continuous improvement by identifying opportunities to reduce redeterminations, complaints, and rework of claims.
• Identify trends and areas of improvement resulting from information obtained through the Resolution team resources and available reporting/data.

• 5 or more years of healthcare services experience in Sales, enrollment, Complaints to Medicare (CTMs)
• 1 or more years auditing experience
• Experience using data analysis tools (such as Excel, SQL, or Power Bi) to create and analyze reports to identify trends
• Demonstrated knowledge using advanced features in Microsoft Excel, including data sorting, pivot tables, and complex formulas.
• Experience managing concurrent projects, maintaining thoroughly documented outcomes and minimal data entry error rates.