Point32Health
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Appeals and Grievance Analyst
role at
Point32Health .
Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, we build 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 care and shared values that guide our behaviors and decisions. We are committed to inclusion and equal healthcare access and outcomes, regardless of background.
Job Summary Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst manages and coordinates member appeals and grievances per State and Federal regulations. The Analyst prepares cases for presentation to the Member Appeals Committee (MAC) and Member Appeal Reconsideration Committee (MARC), ensures compliance with regulatory requirements set by NCQA, DOI, CMS, DOL, and state or federal regulations, and collaborates with members, providers, and internal and external constituents on escalated issues.
Responsibilities
Advocate for members by clearly communicating the appeal and grievance processes both orally and in writing.
Manage assigned member appeals and grievance cases from documentation through resolution, ensuring compliance with regulatory requirements.
Review and interpret product and benefit designs according to state and federal regulatory requirements.
Collect medical, claims, and administrative records needed to research appeals or complaints, coordinating with internal and external customers.
Consult subject matter experts as necessary to gather information for appropriate resolution.
Recommend appeal decisions based on member benefits and individual circumstances presented.
Perform other duties and projects as assigned.
Qualifications
Education:
Associate’s Degree or equivalent experience in health care, conflict resolution, or related field (minimum). Bachelor’s Degree in related field preferred.
Experience:
2-4 years as a customer service or member services representative in health care or insurance (minimum). 2 years’ Appeals and Grievance experience preferred.
Skills:
Knowledge of health care benefits and regulatory requirements preferred. Proficiency in operating Windows applications and other comparable systems. Initiative, judgment, and organization to plan and prioritize work efficiently and comply with regulations. Strong verbal, written, and interpersonal communication skills. Ability to work independently and collaboratively as part of a team.
Working Conditions
Work under normal office conditions; home office allowed as required.
Use of telephone/headset and PC/keyboard for extended durations.
May require additional hours beyond standard schedule.
Weekend coverage may be required on a rotating basis.
Salary Range $22.92 - $34.38 per hour.
Compensation & Total Rewards Overview In addition to base salary, colleagues are eligible for variable pay and a comprehensive benefits package including medical, dental, vision, retirement plans, paid time off, life and disability insurance, tuition program, well-being benefits, and supports for career development, individual and family health, and financial health. For more details, visit
our benefits page .
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 recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals 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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Appeals and Grievance Analyst
role at
Point32Health .
Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, we build 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 care and shared values that guide our behaviors and decisions. We are committed to inclusion and equal healthcare access and outcomes, regardless of background.
Job Summary Under the general direction of the Member Appeals and Grievance Supervisor, the Appeals and Grievance Analyst manages and coordinates member appeals and grievances per State and Federal regulations. The Analyst prepares cases for presentation to the Member Appeals Committee (MAC) and Member Appeal Reconsideration Committee (MARC), ensures compliance with regulatory requirements set by NCQA, DOI, CMS, DOL, and state or federal regulations, and collaborates with members, providers, and internal and external constituents on escalated issues.
Responsibilities
Advocate for members by clearly communicating the appeal and grievance processes both orally and in writing.
Manage assigned member appeals and grievance cases from documentation through resolution, ensuring compliance with regulatory requirements.
Review and interpret product and benefit designs according to state and federal regulatory requirements.
Collect medical, claims, and administrative records needed to research appeals or complaints, coordinating with internal and external customers.
Consult subject matter experts as necessary to gather information for appropriate resolution.
Recommend appeal decisions based on member benefits and individual circumstances presented.
Perform other duties and projects as assigned.
Qualifications
Education:
Associate’s Degree or equivalent experience in health care, conflict resolution, or related field (minimum). Bachelor’s Degree in related field preferred.
Experience:
2-4 years as a customer service or member services representative in health care or insurance (minimum). 2 years’ Appeals and Grievance experience preferred.
Skills:
Knowledge of health care benefits and regulatory requirements preferred. Proficiency in operating Windows applications and other comparable systems. Initiative, judgment, and organization to plan and prioritize work efficiently and comply with regulations. Strong verbal, written, and interpersonal communication skills. Ability to work independently and collaboratively as part of a team.
Working Conditions
Work under normal office conditions; home office allowed as required.
Use of telephone/headset and PC/keyboard for extended durations.
May require additional hours beyond standard schedule.
Weekend coverage may be required on a rotating basis.
Salary Range $22.92 - $34.38 per hour.
Compensation & Total Rewards Overview In addition to base salary, colleagues are eligible for variable pay and a comprehensive benefits package including medical, dental, vision, retirement plans, paid time off, life and disability insurance, tuition program, well-being benefits, and supports for career development, individual and family health, and financial health. For more details, visit
our benefits page .
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 recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals 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