Henry Ford Health System
Appeals & Grievance Analyst (Hybrid - Troy, MI) - Health Alliance Plan
Henry Ford Health System, Troy, Michigan, United States, 48083
Appeals & Grievance Analyst (Hybrid - Troy, MI) - Health Alliance Plan
Responsible for the prompt and thorough investigation of medical and pharmacy member appeals and grievances for Health Alliance Plan’s Commercial, Medicare Advantage, Medicare-Medicaid Program (MMP), and Medicaid lines of business. The analyst must identify trending issues on an ongoing basis and provide root/cause analysis when required. The analyst works 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 keeps abreast of regulatory requirements from state and federal agencies and presents appeal cases to members, senior leaders, and other key stakeholders on an ongoing basis. The analyst provides verbal and written communication to members and providers daily, manages, organizes and prioritizes cases, and supports audits and the development of desk‑level procedures.
Principle Duties and Responsibilities
Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from CMS, Maximus Federal Services, DOL, DIFS, MDHHS, NCQA, OPM, MI Health Link, and the Better Business Bureau.
Strictly adhere to CMS, MI Health Link (MMP), and MDHHS contracts in responses to members, regulatory agencies, and providers.
Provide concise and thorough written responses to members, regulatory agencies, and providers outlining findings and resolution.
Perform case pre‑analysis, procuring appropriate medical records and supporting documentation before sending cases to internal stakeholders for subject‑matter‑expert reviews.
Prepare cases for presentation during relevant hearings (e.g., Administrative Law Judge hearings, Maximus Committee meetings, state fair hearings, second‑level member hearings).
Shadow new employees as part of their onboarding to the Appeal and Grievance Team.
Perform other related duties as assigned.
Education / Experience Required
Minimum 3 years of experience in a customer‑service or provider inquiry call center reviewing member contracts, authorizations, and benefits.
Minimum 2 years of experience reviewing claims.
Successful experience with business writing (demonstrated by passing a writing assessment).
Demonstrated knowledge of Medicare Advantage, federal government Medicare benefits, all commercial (including self‑funded benefit guides, contracts and riders), eligibility and direct‑pay programs and rates.
Skills
Strong analytical and critical‑thinking skills.
Excellent problem‑solving techniques.
High degree of patience, maturity, empathy, tact, diplomacy; ability to work with all levels of the organization.
High degree of poise and good judgment in responding to inquiries with varying customer 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 and HAP’s current documentation system (CareRadius, Pega A&G, Pega CRM, Microsoft Word or equivalent).
Knowledge of medical terminology.
Equal Employment Opportunity Equal Employment Opportunity / Affirmative Action Employer. Henry Ford Health System is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.
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Principle Duties and Responsibilities
Conduct the primary investigation and resolution of member appeals and grievances following established guidelines from CMS, Maximus Federal Services, DOL, DIFS, MDHHS, NCQA, OPM, MI Health Link, and the Better Business Bureau.
Strictly adhere to CMS, MI Health Link (MMP), and MDHHS contracts in responses to members, regulatory agencies, and providers.
Provide concise and thorough written responses to members, regulatory agencies, and providers outlining findings and resolution.
Perform case pre‑analysis, procuring appropriate medical records and supporting documentation before sending cases to internal stakeholders for subject‑matter‑expert reviews.
Prepare cases for presentation during relevant hearings (e.g., Administrative Law Judge hearings, Maximus Committee meetings, state fair hearings, second‑level member hearings).
Shadow new employees as part of their onboarding to the Appeal and Grievance Team.
Perform other related duties as assigned.
Education / Experience Required
Minimum 3 years of experience in a customer‑service or provider inquiry call center reviewing member contracts, authorizations, and benefits.
Minimum 2 years of experience reviewing claims.
Successful experience with business writing (demonstrated by passing a writing assessment).
Demonstrated knowledge of Medicare Advantage, federal government Medicare benefits, all commercial (including self‑funded benefit guides, contracts and riders), eligibility and direct‑pay programs and rates.
Skills
Strong analytical and critical‑thinking skills.
Excellent problem‑solving techniques.
High degree of patience, maturity, empathy, tact, diplomacy; ability to work with all levels of the organization.
High degree of poise and good judgment in responding to inquiries with varying customer 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 and HAP’s current documentation system (CareRadius, Pega A&G, Pega CRM, Microsoft Word or equivalent).
Knowledge of medical terminology.
Equal Employment Opportunity Equal Employment Opportunity / Affirmative Action Employer. Henry Ford Health System is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.
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