Grievance and Appeals Analyst

Company :

Highmark Inc.

Job Description :

JOB SUMMARY

The job conducts and documents thorough investigations of all complaint and grievance case types, communicating resolution to members in accordance with Center for Medicare and Medicaid Services (CMS) requirements. Requires broad knowledge of plan products, processes and enrollment rules. Responsible for all aspects of nonclinical appeals , up to and including decision making, considering potential impacts to regulatory compliance as well as CMS star ratings. Provides support to clinical appeals, facilitating member verbal and written notification and correct authorization of services. CTM complaints, investigation and response to executive and legislative inquiries also performed by the Appeal Analyst.

ESSENTIAL RESPONSIBILITIES

• Complete and document thorough investigation of all grievances and appeals. Perform research and evaluate output requirements and formats. Request and review all related relevant documentation and assemble case file. Ensure accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements. Effectiv...