Grievance Analyst

HealthSmart International; Fort Lauderdale (FL); Hybrid; USD 50,000 - 65,000; Full time

Job summary

Convey Health Solutions is seeking a Grievance Analyst to research and resolve customer complaints within CMS guidelines. The role emphasizes root-cause analysis and appropriate corrective actions, with clear written or verbal communication to customers.

You will document issues, identify trends, and prepare reports for management while maintaining HIPAA compliance and a professional demeanor in a fast-paced healthcare environment.

Qualifications

• Excellent written, verbal, and interpersonal communication skills.
• Strong organizational skills and attention to detail.
• Ability to provide clear and accurate information through multiple media.
• Ability to manage open requests and follow up without outside direction.
• Strong time management and attention to detail.

Responsibilities

• Accurately identify and document customer complaints based on notes and records.
• Research grievance cases to identify root cause and appropriate resolution.
• Convey the identified resolution to the customer verbally or in writing.
• Document resolution and root cause for assigned grievances.
• Report trends in complaints to management for escalation.
• Prepare reports as requested by management.
• Maintain positive demeanor and ensure accuracy and policy conformity.
• Adhere to CMS Guidance in communications.
• Maintain HIPAA compliance in the work environment.
• Document member records clearly and concisely.
• Outreach to validate information and addresses when needed.
• Communicate professionally with coworkers, management, and customers.
• Follow all regulations, policies, and work instructions.
• Respond promptly to correspondence and faxes.
• Present a professional image in appearance and behavior.

Skills

Communication

Writing skills

Interpersonal skills

Organizational skills

Time management

Education

High School Diploma

Associate/Bachelor preferred

Job description

About Us Convey Health Solutions, together with Pareto Intelligence™, delivers a powerful combination of purpose-built technology, advanced analytics, and expert services to help health plans thrive in a complex, post--Affordable Care Act environment. As a trusted partner to Medicare and commercial payers, we provide scalable, compliant solutions that span the entire member lifecycle--from enrollment and billing to risk adjustment, Stars performance, and member engagement. Pareto's deep analytics and financial intelligence complement Convey's operational expertise, enabling our clients to improve performance, reduce costs, and create better healthcare experiences for millions of Americans--especially seniors and vulnerable populations. Together, we help health plans scale smarter, grow stronger, and make healthcare work better for the people who need it most. Learn more at http://www.ConveyHealthSolutions.com

Job Description

Job Title: Grievance Analyst

Position Summary:

The Grievance Analyst is responsible for the timely and accurate research and resolution, within CMS guidelines, of customer complaints with added focus on root cause analysis and, when necessary, systemic and process correction recommendations. Identified resolutions will be communicated to customers verbally and/or in writing based on the method of delivery and customer request.

Key Duties and Responsibilities:

• Accurately identify and document customer complaints based upon notes received from customer service, correspondence received from the customer and/or review of the recorded customer interaction
• Utilize knowledge of program processes and systems to research assigned grievance cases in their entirety to identify the cause of received complaints and identify a resolution appropriate to the situation
• Convey the identified resolution to the customer or his/her representative either in writing or verbally
• Identify and document the resolution and root cause for any assigned grievances including accurate
• Report identified trends in complaints and root causes to management for escalation
• Prepare reports as requested by management.
• Display positive demeanor, technical accuracy, and conformity to company policies.
• Understand CMS Guidance and ensure that communication is in accordance with CMS Guidance.
• Ensure HIPAA regulations are maintained within the immediate environment.
• Documentation is detailed and concise as it pertains to member records.
• Identifies need for outbound calls for purposes of validating information and addresses and conducts member outreach.
• Communicate with coworkers, management, staff, customers, and others in a courteous and professional manner.
• Conform with and abide by all regulations, policies, work procedures and instructions.
• Respond promptly when replying to correspondence and faxes.
• Act, dress, and behave in a professional manner to reflect a positive image of the company.

Education and Experience:

• High School Diploma. Associate’s or Bachelor’s Degree preferred
• Three to five years’ customer service experience in a federally regulated or insurance related field.
• Excellent writing skills

Knowledge, Skills, and Abilities:

• Excellent written, verbal, and interpersonal communication skills
• Excellent organizational skills and attention to detail
• Ability to provide clear and accurate information through multiple media
• Ability to manage open requests and follow up when necessary without outside direction
• Ability to effectively manage time with strong attention to detail
• Ability to read and interpret documents including safety rules, operating and maintenance instructions, procedure manuals and general correspondence
• Ability to write routine reports and correspondence
• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
• Ability to carry out instructions furnished in written, oral, or diagram form
• Ability to deal with problems involving several concrete variables in standardized situations
• Ability to politely, tactfully and firmly interact with a wide range of people and personalities
• Ability to work in an environment with potential interruptions
• Must be able to operate computer, calculator, copier, fax machine, phone and other office equipment

Company

Convey -- US

Convey Health Solutions

Equal Employment Opportunity Statement:

Convey Health Solutions is an Equal Opportunity Employer committed to fostering an inclusive and diverse workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

Convey Health Solutions also provides reasonable accommodations to qualified individuals with disabilities in accordance with applicable laws. Applicants requiring accommodation during the application or interview process should contact the Human Resources department.

EEO is the Law