Member Appeal Analyst

Job description

Job Summary Responsible for the analysis, research and completion of complex member appeal investigations. Effectively administer all steps of the member appeal and fair hearing processes for all non-Medicare products to thoroughly investigate appeal requests, leveraging critical thinking skills, gathering relevant information from enterprise-wide systems, and collaboration to resolve issues whenever possible. Ensure compliance with all mandated, legislative, regulatory and accreditation requirements. Assist customers and staff throughout the process by providing complete information and follow up on a timely basis. Ensure committee, State and Federal decisions are properly implemented. Assist the Lead, Supervisor and/or Manager in coordinating activities and in the development/collection of materials required to meet and demonstrate compliance to all state, federal and accrediting organization requirements. Essential Functions: Responsible for complex and thorough investigation of appeals, external complaints, and fair hearing reviews including: formulate action plan to ensure all activities are completed by the regulatory time line, gather all relevant information for the appeal...