Medicare Grievances & Appeals Analyst

Solis Health Plans; Town of Florida (NY); 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

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