Grievance, Claims & Appeals Analyst

Media Riders Inc.; Oklahoma; Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company in healthcare services is seeking a Grievances and Appeals Analyst to handle complex cases and provide expert opinions. This fully remote position requires strong communication and analytical skills, along with a background in dental and healthcare administration. The ideal candidate will demonstrate excellent time management and a team-oriented attitude, ensuring compliance with regulatory guidelines while resolving member grievances efficiently.

Qualifications

• Minimum 3 years in dental background.
• 2 years in healthcare administrative support.

Responsibilities

• Investigate and resolve member grievances and appeals.
• Process appeals within regulatory guidelines.
• Communicate with members, providers, and partners.

Skills

Time Management

Communication

Dental Insurance Experience

Quality Management

Education

High School diploma or GED

Tools

MS Word

Excel

Job description

Direct message the job poster from Media Riders Inc.

A Recruiting BEAST / Team Leader / Manager

Fully REMOTE Opportunity

Job Summary Details

1. The Grievances and Appeals Analyst will be responsible for investigating and resolving member, Health Plan Partner-member, and network provider grievances and appeals.
2. Identify, analyze, and research pre- and post-service denials for members and providers to identify discrepancies, errors, and determine appropriate actions.
3. Process all appeals within regulatory guidelines.
4. Respond in writing to members and providers, making informed judgments on benefits, claims, referrals, and other issues by conducting timely investigations.
5. Verify information related to data entry, claims submissions, and workflow processes to ensure timely reimbursement.
6. Demonstrate a team-oriented attitude by following supervisor directions, interacting well with coworkers, and adhering to policies and procedures.
7. Interface professionally with internal and external entities.
8. The Analyst I will also handle occasional intake of grievances and appeals.

Distinguishing Characteristics

G&A Analyst II

• Acts as a subject matter expert, collaborating on complex cases and providing benefit/clinical opinions.
• Performs duties of Analyst I.
• Responds to staff questions, assists with training, and implements policies.
• Identifies concerns and develops strategies to meet department goals.
• Handles all levels of grievances and appeals, including fair hearings.

G&A Analyst III

• Investigates highly complex grievances and appeals, including disputes involving high reimbursements and quality of care.
• Responds to regulatory complaints from agencies like DMHC, DHCS, DOI.
• Monitors notices for fair hearings and information requests.
• Communicates with members, providers, and partners for case updates.
• Assists in monitoring daily operations and developing policies.
• Participates in grievance committee meetings and presents agenda items.

Education Requirements

Minimum

• High School diploma or GED

Years of Experience

• Minimum: 3 years in dental background
• 2 years in healthcare administrative support

Specific Skills/Knowledge

• Dental insurance experience preferred
• Experience in Quality Management preferred
• Excellent time management and ability to meet deadlines
• Intermediate MS Word and Excel skills
• Strong written and verbal communication skills
• Knowledge of applicable laws and regulations, including CMS guidelines
• Availability for overtime

Additional Details

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job functions: Analyst, Customer Service, Administrative
• Industries: Claims Adjusting, Actuarial Services, Health and Human Services, Hospitals and Healthcare