Appeals Analyst

Job description

Company: Highmark Inc. Job Description: JOB SUMMARY This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results. ESSENTIAL RESPONSIBILITIES: - Review inquiries to determine if they meet definition of appeal/grievance. - Request and review all related relevant documentation and assemble case file. - Coordinate resolution results and relay investigative results with all involved parties. - Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends. - May support the Quality Assurance, Appeal and other quality committees. - Other duties as assigned or requested. EDUCATION: Required: - High School Diploma or GED Substitutions: - None Preferred: - None EXP...