Appeal - Grievance Analyst I

Job Description:

This position provides expertise in the areas of appeals and grievances for highly regulated insurance plans with unique plan designs, compliance requirements, regulatory legislation and NCQA, (National Committee for Quality Assurance), standards. These include commercial employer group, individual and government insurance programs such as Medicare, Medicaid, Affordable Care Act (ACA), Children's Health Insurance Program (CHIP), Federal Employees Health Benefit (FEHB) program and self-funded plans.

We are committed to offering flexible work options where approved and stated in the job posting. However, we are currently not considering candidates who reside or plan to reside in the following states: California, Connecticut, Hawaii, Illinois, New York, Rhode Island, Vermont, and Washington.

Please note that a video interview through Microsoft Teams will be required as well as potential onsite interviews and meetings

This analyst position investigates, examines and reviews appeals and grievances in accordance with state and federal insurance regulations, government regulations, and NCQA standards for all members and their authorized representatives. It communicates regularly with various levels of the organization to resolve appeals and grievances and serves as a resource to various departments regarding appeal and grievance issues. This position:

• Conducts research and analysis of complex information in conjunction with established coverage and medical policies.
• Assesses written and verbal complaints, identifies all areas of dissatisfaction and works closely with other departments to research and resolve issues.
• Organizes and analyzes appeals and grievances, including making complex decisions with minimal supervision within the scope of the appeals and grievance resolution standards.
• Educates various departments on current appeal and grievance trends along with applicable regulatory and accreditation requirements as they pertain to the appeals procedures. Serves as a resource regarding appeals and grievance issues and current trends in the appeals arena.
• Successfully conducts impartial appeal reviews with the legal department, compliance specialists, medical directors and various leadership members.
• Prepares appeals for review by appropriate committees, internal medical directors, and specialty physician reviews.
• Stays current with emerging medical technology and pharmaceutical formulary (preferred drugs) changes. Maintains an in depth understanding of various insurance products, medical policies, regulatory requirements, and accreditation standards through available education and individual research.
• Provides expertise on claims adjudication and benefits for all plans, including commercial, self-funded, Medicare, Medicaid, as well as other government sponsored plans.
• Maintains appropriate documentation and performs analysis on appeals for other departments and employer groups.
• 10. Proactively resolves varied and complex appeals and negotiating issues.

Minimum Qualifications

• Demonstrated experience as a SelectHealth Health Benefit Specialist, (HBS), or demonstrated experience in health insurance benefits customer service.
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• Demonstrated beginner level computer literacy in word processing, spreadsheet applications.

Preferred Qualifications

• SelectHealth experience.
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• Experience in Facets and AWD systems.
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• Work experience using medical terminology or the completion of a medical terminology course.
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• Demonstrated ability to handle intense emotions and to guide conversations to a satisfactory resolution for all parties.
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• Excellent analytical, fact-finding, problem solving and organizational skills.
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• Ability to professionally communicate verbally and in writing with staff, members, and providers.
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• Experience working with minimal or no direct supervision.
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• Demonstrated ability to work successfully in a team setting.

Physical Requirements:

SH only

Hearing, Manual Dexterity, Seeing, Speaking

Location:

SelectHealth - Murray

Work City:

Murray

Work State:

Utah

Scheduled Weekly Hours:

40

The hourly range for this position is listed below. Actual hourly rate dependent upon experience.

$21.84 - $33.23

We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.

Learn more about our comprehensive benefits package here.

Intermountain Health is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

At Intermountain Health, we use the artificial intelligence ("AI") platform, HiredScore to improve your job application experience. HiredScore helps match your skills and experiences to the best jobs for you. While HiredScore assists in reviewing applications, all final decisions are made by Intermountain personnel to ensure fairness. We protect your privacy and follow strict data protection rules. Your information is safe and used only for recruitment. Thank you for considering a career with us and experiencing our AI-enhanced recruitment process.

All positions subject to close without notice.