Grievance and Appeals CTM Analyst

Solis Health Plans, Inc.; Florida; On-site; USD 55,000 - 85,000; Full time

Job summary

Solis Health Plans in Doral, FL is seeking a Grievance and Appeals CTM Analyst to review, investigate, and resolve member complaints submitted through CMS CTM. The role requires meticulous analysis, strong knowledge of Medicare Advantage operations, and the ability to coordinate with various departments to ensure timely responses.

You will analyze cases, document findings, monitor turnaround times, and escalate complex issues as needed, contributing to regulatory compliance and improved member

Qualifications

• High school diploma or equivalent; associate or bachelor’s degree 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.
• Strong analytical, organizational, and problem-solving skills.
• Excellent written and verbal communication; ability to interpret policies and regulatory requirements.
• Strong attention to detail; ability to manage multiple cases and deadlines.
• Proficiency with Microsoft Office and healthcare databases or case-management systems.

Responsibilities

• Review and investigate member complaints through CMS CTM and other channels.
• Analyze information to determine facts and appropriate resolution.
• Coordinate with internal departments and delegated entities 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 in tracking systems.
• Monitor assigned complaints to ensure timely CMS and organizational turnaround times.
• Review documentation for accuracy and regulatory compliance.
• Escalate complex or non-compliant issues to management or compliance departments.
• Identify recurring complaint trends and needed corrective actions.
• Assist with complaint reporting, audits, quality reviews, and regulatory inquiries.
• Maintain confidentiality of protected health information.

Skills

Medicare Advantage

Grievances & Appeals

Healthcare operations

Regulatory compliance

Analytical skills

Communication

Attention to detail

Case research

Education

High school diploma

Healthcare admin/public health degree preferred

Tools

Microsoft Office

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.