Appeals & Grievances Analyst

2 weeks ago

Manila, National Capital Region, Philippines UST Full time

Job Summary:

Acting in a quality assurance capacity, Appeals and Grievances Analysts are responsible for processing appeals and grievances by evaluating the organization's initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case. All appeals and grievance cases must be documented in the highest quality possible, ensuring the appeals and grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations.

Responsibilities:

Follow Grievances and Appeals processes and systems to ensure data quality to support UST HealthProof's quality, production and financial goalsInvestigate and thoroughly document findings on all grievances and appealsPrepare Appeal case recommendations for initial review processCoordinate appropriate reviewer assignment for Appeals and Grievance casesResponsible to move Appeals and Grievances through each review level to ensure timely completionDrive operational excellence into all processes and departmental interactions based on CMS and UST HealthProof's requirementsBring to management's attention any system or process issues determined during the investigation of the appeal or grievanceCoordinate effectively with the Information technology department on upgrades/fixes/changesParticipate in the departmental audit/oversight program that focuses on continuous quality improvementParticipate in compliance committees to help continuously improve initial decision making Requirements:Bachelor's degree in business administration, Economics, Health Care, Information Systems, Statistics or other related field is required. Master's Degree in related field preferred. Relevant combination of education and experience may be considered in lieu of degreeCertification or progress toward certification is highly preferred and encouragedExperience in a grievance and appeals environment, including experience with the grievance and appeals regulations per CMSExperience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plansExperience working in or with Medicare Advantage plans, or Independent Review EntitiesExperience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processesKnowledge in claims, authorizations, and Medicare Advantage plansProven problem-solving skills and ability to translate knowledge to corporate departmentsStrong communication skills are required to understand, interpret, and communicate ideasStrong analytical, organizational, planning, and problem-solving skillsAbility to effectively interface with employees at all levelsAbility to define problems, collect data, establish facts, and draw valid conclusionsDemonstrated track record of generating results and having an impact on organizationsStrong focus and drive to serve the customerAbility to work in a high paced environmentAbility to consistently meet deadlines

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