Grievance and Appeals CTM Analyst

Solis-Health-Plans; Florida; On-site; USD 55,000 - 75,000; Full time

Job summary

Solis-Health-Plans in Doral, FL is seeking a Grievance and Appeals CTM Analyst to review, investigate, track, and resolve member complaints under CMS CTM requirements. You will collaborate with internal teams, delegated entities, providers, and stakeholders to ensure timely, compliant responses while maintaining confidentiality of protected health information.

This role emphasizes attention to detail, regulatory knowledge, and strong communication to improve member experience and regulatory

Qualifications

• High school diploma or equivalent required; degree preferred in healthcare or related field.
• Experience with Medicare Advantage, health insurance, or grievances and appeals preferred.
• Familiarity with CMS requirements and health plan operations is a plus.
• Strong analytical, organizational, and problem-solving abilities with attention to detail.

Responsibilities

• Review and investigate member complaints through CMS CTM and other channels.
• Analyze records to determine facts and appropriate resolutions within timelines.
• Coordinate with internal departments and delegated entities to gather information.
• Identify potential compliance, service, or benefit issues and document findings.
• Monitor progress to ensure adherence to CMS and internal turnaround times.
• Escalate complex or non-compliant cases to management as needed.
• Assist with complaint reporting, audits, and regulatory inquiries.

Skills

Analytical thinking

Organizational skills

Problem solving

Communication skills

Attention to detail

Policy interpretation

Education

HS diploma

AA/BA preferred

Tools

MS Office

CMS/case-management systems

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Grievance and Appeals CTM Analyst

Full Time Doral, FL, US

3 days ago Requisition ID: 1536

Position Summary

The Grievance and Appeals CTM Analyst is responsible for reviewing, investigating, tracking, and resolving member complaints. This position supports regulatory compliance by ensuring complaints received through the Centers for Medicare & Medicaid Services (CMS) Complaint Tracking Module (CTM) are thoroughly researched, accurately documented, and resolved within established regulatory and organizational timeframes.

The analyst works collaboratively with internal departments, delegated entities, providers, and other stakeholders to investigate complaint issues, identify appropriate resolutions, and ensure timely and accurate responses. The role requires strong attention to detail, critical-thinking skills, knowledge of Medicare Advantage operations, and the ability to interpret and apply CMS requirements and health plan policies.

• Review and investigate member complaints received through the CMS Complaint Tracking Module (CTM) and other applicable channels.
• Analyze complaint information, member history, claims, authorizations, provider records, correspondence, and other documentation to determine the facts and appropriate resolution.
• Conduct research and coordinate with internal departments and delegated entities to obtain information necessary to resolve complaints.
• Identify potential compliance, operational, service, access-to-care, claims, authorization, provider, or benefit-related issues.
• Document investigative findings, actions taken, and resolutions accurately and completely within applicable tracking systems.
• Monitor assigned complaints to ensure they are addressed within required CMS and organizational turnaround times.
• Review documentation for accuracy, completeness, consistency, and compliance with applicable requirements.
• Communicate findings and resolution recommendations to appropriate departments and stakeholders.
• Escalate complex, sensitive, or potentially non-compliant issues to management or the appropriate compliance department.
• Identify recurring complaint trends and potential root causes that may require corrective action or process improvement.
• Assist with complaint reporting, audits, quality reviews, and regulatory inquiries as needed.
• Maintain confidentiality and handle protected health information in accordance with organizational policies and applicable privacy requirements.
• Participate in process-improvement initiatives designed to improve member experience, complaint resolution, and regulatory compliance.
• Maintain current knowledge of plan requirements, CMS guidance, organizational policies, and applicable complaint and grievance procedures.

Qualifications

• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, public health, or a related field preferred.
• Experience in Medicare Advantage, managed care, health insurance, healthcare operations, member services, grievances and appeals, quality, or compliance preferred.
• Familiarity with CMS requirements and Medicare Advantage operations preferred.
• Experience reviewing and investigating member complaints or conducting case research strongly preferred.
• Strong analytical, organizational, and problem-solving skills.
• Excellent written and verbal communication skills.
• Ability to interpret policies, procedures, and regulatory requirements.
• Strong attention to detail and ability to manage multiple cases and deadlines simultaneously.
• Proficiency with Microsoft Office and healthcare-related databases or case-management systems.