Grievance and Appeals Analyst I

Position Summary The Grievance and Appeals Analyst I is responsible for the review, investigation, and resolution of member grievances and appeals within a managed‑care health plan. The analyst ensures all activities are conducted in compliance with regulatory requirements, including those established by the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA), supporting timely, accurate, and compliant resolution of member and provider complaints while maintaining a high standard of customer service and operational excellence. Key Responsibilities Conduct comprehensive review, investigation, and resolution of member grievances, appeals, and complaints in accordance with CMS, NCQA, and state regulatory guidelines. Research and analyze claims, benefit plans, authorizations, and supporting documentation to determine appropriate outcomes. Ensure all cases are processed within mandated regulatory and internal timelines. Request, review, and interpret medical records, provider documentation, and itemized bills as needed to support case determinations. Apply contract language, benefit structures, medical policies, and coverage guidelines to grievance and appeals decisions. Collaborate with internal departments (e.g., Medical Management, Provider Relations, Compliance) to ensure accurate and consistent resolutions. Identify root causes of issues, including claims processing errors, system configuration discrepancies, or provider billing concerns. Prepare clear, concise, and compliant written correspondence to members, providers, and authorized representatives outlining determinations. Document all case activity, findings, and outcomes in accordance with audit and regulatory requirements. Track and report trends in grievances and appeals to support quality improvement initiatives. Communicate with members and providers via written and verbal channels to obtain additional information or clarify case details. Meet or exceed departmental productivity and quality performance standards. Qualifications and Education Required Qualifications Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing; or an equivalent combination of education and experience. Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances. Understanding of NCQA standards related to member complaint and appeals processes. Experience reviewing claims, including eligibility, coordination of benefits, and denial management. Strong analytical and problem‑solving skills with attention to detail. Excellent written and verbal communication skills, with the ability to compose regulatory‑compliant correspondence. Strong organizational and time‑management skills with the ability to manage multiple priorities and meet strict deadlines. Proficiency in Microsoft Office applications and relevant claims or case management systems. Preferred Qualifications Experience working in a managed care organization supporting Medicaid, Medicare Advantage, or Marketplace plans. Familiarity with medical terminology, coding, and utilization management processes. Prior experience handling complex or escalated grievance and appeals cases. Background in a healthcare setting such as a hospital, provider office, or health‑plan operations. #J-18808-Ljbffr Solis Health Plans