Appeals and Grievance Analyst

About Point
32

Health

Point
32

Health is a leading not-for-profit health and well‑being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2,000,000 members, Point
32

Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone.

Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst is responsible per state and federal regulations for the professional and compliant management and coordination of assigned member appeals and grievances received by Point
32

Health. The analyst collaborates with members, their authorized representatives, and other constituents, demonstrating superior customer service and benefit‑interpretation skills. Responsibilities include preparing cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC), coordinating written documentation and correspondence, and handling highly escalated issues.

• Act as a member advocate and clearly communicate the appeal and grievance process both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation to investigation and resolution, ensuring compliance with regulatory requirements (NCQA, DOI, CMS, DOL and relevant state/federal regulations).
• Review and interpret product and benefit designs for all lines of business according to state and federal regulations.
• Collect documents and records (medical, claims, administrative) needed for research of the appeal or complaint.
• Consult with subject‑matter experts as necessary to gather information for appropriate resolution.
• Make recommendations on appeal decisions based on the member’s benefits and circumstances presented.
• Perform other duties and projects as assigned.

• Required (minimum):
  Associate’s Degree or equivalent experience in healthcare, conflict resolution, or a related field.
• Preferred:
  Bachelor’s Degree in a related field.

• Required (minimum): 2‑4 years as a customer service or member services representative in healthcare or insurance.
• Preferred: 2 years of Appeals and Grievance experience.

• Health‑care benefit and regulatory knowledge preferred.
• Knowledge of insurance products, policies, and procedures preferred.
• Proficiency in operating a computer and related equipment, including Windows applications.
• Initiative, balanced judgment, objectivity and ability to plan and prioritize work independently.
• Ability to maintain timelines and turnaround times to meet regulatory requirements.
• Strong analytical, problem‑solving, and investigative skills.
• Excellent verbal and written communication skills.
• Superior customer‑service and interpersonal skills.
• Capacity to work independently and collaboratively as part of a team.

• Work under normal office conditions and work from home as required.
• Simultaneous use of telephone/headset and PC/keyboard and extended sitting may be required.
• May need additional hours beyond the standard schedule.
• Weekend coverage may be required on a rotating basis, as regulated for the line of business.
• Occasional weekend or evening hours may be required.

The above statements describe the general nature and level of work performed by employees assigned to this classification. They are not intended to be an exhaustive list of all responsibilities, duties, and skills required. Management retains discretion to add or change duties of the position at any time.

$23.02 – $34.53

The annual base salary range reflects the range for this role and similar roles across the organization. The actual salary will be determined by factors such as scope, complexity, skills, education, training, credentials, and experience. Colleagues may be eligible for variable pay. Eligibility and terms are at the company’s discretion and consistent with the law.

• Medical, dental, and vision coverage.
• Ret…