Point32Health
Appeals and Grievance Analyst
Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around community of care and shared values that guide our behaviors and decisions. We maintain a long-standing commitment to inclusion and equal healthcare access, regardless of background. We value the rich mix of backgrounds, perspectives, and experiences of all our colleagues, which helps us deliver service with empathy and better understand and meet the needs of the communities where we serve, live, and work.
Job Summary Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst is responsible for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health, in accordance with state and federal regulations. This analyst works collaboratively with members and/or their authorized representatives, demonstrating superior customer service and benefit interpretation skills in all interactions. They prepare cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC), and participate in committee discussions when needed. Responsibilities include developing and coordinating written documentation and correspondence to members outlining final disposition of appeals or grievances and providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues.
Job Description
Act as a member advocate; clearly communicate the appeal and grievance process and procedures both orally and in writing.
Manage assigned member appeals and grievance cases from documentation to investigation and through resolution, ensuring final disposition is compliant with regulatory requirements set forth by NCQA, DOI, CMS, DOL, and any applicable state or federal regulations.
Review and interpret product and benefit designs for all lines of business according to state and federal regulatory requirements.
Collect documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with internal and external customers.
Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
Perform other duties and projects as assigned.
Qualifications – What You Need To Perform The Job Education
Required (minimum): Associate’s Degree or equivalent experience in health care, conflict resolution or related field.
Preferred: Bachelor’s Degree in a related field.
Experience
Required (minimum): 2-4 years’ experience as a customer service or member services representative in health care or insurance.
Preferred: 2 years’ Appeals and Grievance experience.
Skill Requirements
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 and comparable systems.
Initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize work to assure maximum efficiency and compliance.
Ability to organize, plan and implement Member Appeals and Grievances functions, maintain timelines and turnaround times to meet multiple regulatory requirements.
Ability to synthesize complex information and deliver it verbally and written, in a clear, concise, and articulate manner.
Excellent interpersonal skills to communicate and work with multiple constituents.
Understanding and compliance with state and federal regulations.
Superior investigation, analytical and problem‑solving skills.
Excellent customer service and interpersonal skills.
Ability to work independently and collaborate as part of a team.
Working Conditions and Additional Requirements
Must be able to work under normal office conditions and work from home as required.
Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
May be required to work additional hours beyond the standard work schedule.
Weekend coverage may be required on a rotating basis as regulated for line of business.
May require occasional weekend or evening hours as business needs dictate.
Disclaimer The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Salary Range $22.92 - $34.38
Compensation & Total Rewards Overview The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary will be determined by several factors, including scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or other form of compensation remains at the Company’s sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Benefits
Medical, dental and vision coverage
Retirement plans
Paid time off
Employer‑paid life and disability insurance with additional buy‑up coverage options
Tuition program
Well‑being benefits
Full suite of benefits to support career development, individual & family health, and financial health
EEO Statement All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Scam Alert Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org.
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Job Summary Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst is responsible for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health, in accordance with state and federal regulations. This analyst works collaboratively with members and/or their authorized representatives, demonstrating superior customer service and benefit interpretation skills in all interactions. They prepare cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC), and participate in committee discussions when needed. Responsibilities include developing and coordinating written documentation and correspondence to members outlining final disposition of appeals or grievances and providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues.
Job Description
Act as a member advocate; clearly communicate the appeal and grievance process and procedures both orally and in writing.
Manage assigned member appeals and grievance cases from documentation to investigation and through resolution, ensuring final disposition is compliant with regulatory requirements set forth by NCQA, DOI, CMS, DOL, and any applicable state or federal regulations.
Review and interpret product and benefit designs for all lines of business according to state and federal regulatory requirements.
Collect documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with internal and external customers.
Consult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.
Make recommendations on appeal decisions based on the member’s benefits and individual circumstances presented.
Perform other duties and projects as assigned.
Qualifications – What You Need To Perform The Job Education
Required (minimum): Associate’s Degree or equivalent experience in health care, conflict resolution or related field.
Preferred: Bachelor’s Degree in a related field.
Experience
Required (minimum): 2-4 years’ experience as a customer service or member services representative in health care or insurance.
Preferred: 2 years’ Appeals and Grievance experience.
Skill Requirements
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 and comparable systems.
Initiative, balanced judgment, objectivity, and the ability to independently plan and prioritize work to assure maximum efficiency and compliance.
Ability to organize, plan and implement Member Appeals and Grievances functions, maintain timelines and turnaround times to meet multiple regulatory requirements.
Ability to synthesize complex information and deliver it verbally and written, in a clear, concise, and articulate manner.
Excellent interpersonal skills to communicate and work with multiple constituents.
Understanding and compliance with state and federal regulations.
Superior investigation, analytical and problem‑solving skills.
Excellent customer service and interpersonal skills.
Ability to work independently and collaborate as part of a team.
Working Conditions and Additional Requirements
Must be able to work under normal office conditions and work from home as required.
Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
May be required to work additional hours beyond the standard work schedule.
Weekend coverage may be required on a rotating basis as regulated for line of business.
May require occasional weekend or evening hours as business needs dictate.
Disclaimer The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.
Salary Range $22.92 - $34.38
Compensation & Total Rewards Overview The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary will be determined by several factors, including scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or other form of compensation remains at the Company’s sole discretion and may be modified at the Company’s sole discretion, consistent with the law.
Benefits
Medical, dental and vision coverage
Retirement plans
Paid time off
Employer‑paid life and disability insurance with additional buy‑up coverage options
Tuition program
Well‑being benefits
Full suite of benefits to support career development, individual & family health, and financial health
EEO Statement All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
Scam Alert Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org.
#J-18808-Ljbffr