Grievance & Appeal Analyst

Overview Verda Healthcare, Inc. is a Medicare Advantage Prescription Drug Plan (MAPD) organization committed to easily and equitably accessible healthcare. We are currently operating in Texas and Arizona and aim to ensure underserved communities have access to health and wellness services. We are seeking a Grievance & Appeal Analyst to join our team. Position Grievance & Appeal Analyst This role responds to written/verbal grievances, complaints, appeals and disputes submitted by members and providers. Responsibilities include reviewing, analyzing, researching, resolving and responding to all types of grievances and appeals in accordance with CMS and other regulatory guidelines, as well as internal policies. The analyst will collaborate with Clinical departments regarding clinical policy appeals and act as an interface between internal and external customers, maintaining strong member and provider relations. This position is part of the Call Center and reports to the Director of Enrollment. Responsibilities Review and evaluate appeal and grievance requests to identify and classify member and provider appeals; hand off to the appropriate department for provider and clinical appeals; process member and provider complaints to meet CMS, state and accreditation requirements. Determine eligibility, benefits, and prior activity related to claims, payment, or service in question. Research and review materials from operational areas to ensure appropriate resolution; review contracts, member materials, medical payment policies, and provider education documents when deciding outcomes. Ensure compliance with state and federal regulations in review and determination of appeals and grievances. Conduct thorough investigations of member and provider correspondence, analyzing issues and obtaining responses from internal and external entities. Perform comprehensive research related to member complaints, classifying as grievance, appeal, or both, in accordance with regulatory requirements. Review appeal files for completeness and accuracy; consult with internal areas (e.g., Legal Department) for legal implications of complex appeals. Provide written acknowledgments and responses to member and provider correspondence addressing issues accurately and clearly. Follow up with responsible departments to ensure compliance and timely resolutions. Make verbal contact with members or authorized representatives as needed to clarify issues during the research process. Document service requests, track resolution, and capture required data to enable accurate reporting, tracking, and trending. Provide follow-up documentation of outcomes to practitioners, providers, and members. Ensure timely, complete, and accurate documentation of appeals and/or grievances, and communicate resolutions to members and/or providers. Prepare and submit appeal case files to the IRE within required timelines (up to 24 hours for expedited appeals; 30 days for standard pre-service appeals; 60 days for claim appeals). Enter and maintain critical data and records to support business requirements, regulatory obligations and NCQA standards; monitor timeframes and reports. Track and trend outcomes and provide reporting to identify education opportunities for providers and continuous improvement opportunities. Collaborate with medical groups, network physicians, and internal departments to resolve complex claim issues and educate stakeholders. Requirements Associate’s degree required; Bachelor’s degree preferred. In lieu of a degree, equivalent education and/or experience may be considered. 3+ years of related, professional work experience. 2 years of experience in Medicare Managed Care preferred. Experience in a managed care/compliance environment preferred. Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits, and all types of medical claims. Solid understanding of member and provider rights and responsibilities, particularly regarding appeals and grievances. Familiarity with managed care state and federal regulations. Prior auditing experience and customer service experience preferred. Knowledge of medical terminology and prior ACD experience; ability to present written information clearly and communicate concisely at an executive level. Demonstrated good judgment, organization, prioritization, and time management skills; proven leadership with staff, projects, and management; strategic thinking and analytical abilities. Professional Competencies Integrity and Trust Customer Focus Functional/Technical Skills Written and Oral Communications Critical and Analytical Thinking Compensation and Benefits Location: Huntington Beach, CA (onsite) Compensation: $27 – $31 hourly. Actual compensation offered will be based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may be eligible for performance-based incentive compensation and benefits. 401(k) Paid time off (vacation, holiday, sick leave) Health, dental, and vision insurance Life insurance Schedule Full-time onsite (100% in-office) Hours: 9:00 am – 6:00 pm Standard business hours Monday to Friday; weekends as needed Occasional travel may be required for meetings and training Ability to Commute/Relocate Must reliably commute to the office location or plan to relocate before starting. Physical Demands Regularly sit or walk at a workstation in an office setting. Must occasionally lift and/or move up to 25-50 pounds. Equal Opportunity Employer Verda Healthcare, Inc. is an equal opportunity employer. We value diversity and are committed to creating an inclusive environment for all employees. #J-18808-Ljbffr Verda Healthcare