Appeals & Grievance Analyst; Hybrid - Troy, MI

General Summary

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, the analyst will 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 daily. Ability to manage, organize and prioritize cases, and complete within required time frames. The analyst will also provide necessary support for audits and the development of desk‑level procedures.

• Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from the Center for Medicaid and Medicare Services (CMS), MAXIMUS Federal Services, Department of Labor (DOL), Department of Insurance and Financial Services (DIFS), Michigan Department of Health and Human Services (MDHHS), National Committee for Quality Assurance (NCQA), Office of Personnel Management (OPM), MI Health Link, and Better Business Bureau (BBB).
• Demonstrate strict adherence to the Centers for Medicare and Medicaid (CMS), MI Health Link (MMP), and Michigan Department of Health and Human Services (MDHHS) contracts in responses to members, regulatory agencies, and providers.
• Provide concise and thorough written responses to members, regulatory agencies, and providers on the findings of investigations and resolution.
• Perform case pre‑analysis; procure appropriate medical records and supporting documentation prior to sending the case to internal stakeholders for subject‑matter expert reviews, working cross‑departmentally for resolution.
• Prepare cases for presentation during pertinent hearings (e.g., Administrative Law Judge hearings, MAXIMUS Committee Meetings, State Fair Hearings, Second‑Level Member Hearings).
• Provide shadowing to new employees as part of their onboarding to the Appeal and Grievance Team.
• Perform other related duties as assigned.

• Associate degree in healthcare or a related field.
• Minimum of three (3) years of experience in a Customer Service or Provider Inquiry call center; reviewing member contracts, authorizations, and benefits.
• Minimum of two (2) years of experience reviewing claims.
• Must have successful experience with business writing, demonstrated by passing a writing assessment.
• Demonstrated knowledge of the Medicare Advantage, federal government, Medicare benefits, all commercial including self‑funded benefit guides, contracts and riders, eligibility and direct pay programs, and rates.

• Strong analytical and critical thinking skills.
• Excellent problem‑solving techniques.
• High degree of patience, maturity, empathy, tact, and diplomacy; able to work with all levels of people within the organization.
• High degree of poise and good judgment in responding to inquiries from customers with varying attitudes; excellent written, listening, and verbal communication skills.
• Flexibility and ability to handle multiple priorities through organizational and time‑management skills.
• Demonstrated ability to work in a Windows environment, HAP’s current documentation system (Care Radius, Pega A&G, Pega CRM, and Microsoft Word), or an equivalent documentation system.
• Knowledge of medical terminology.

• Organization: HAP (Health Alliance Plan)
• Department:
  Appeals and Grievances
• Henry Ford Health
  
  Location:
  
  HAP (Health Alliance Plan)
• Shift: Day Job
• Union Code:
  Office/Non‑Exempt, HAP