Appeals and Grievance Analyst- Senior Care Division

BlueCross BlueShield of Tennessee • Chattanooga, TN

2d • Remote

About The Position

The Appeals & Grievance team is expanding and seeking a Member Appeals & Grievance Analyst to join our team. As a Member Appeals & Grievance Analyst, you will be responsible for reviewing and processing appeals and grievances submitted by Members and Providers. Your daily responsibilities will include accurate data entry, evaluating cases to determine appropriate next steps in compliance with CMS guidelines, and managing multiple tasks within required turnaround times. This role is ideal for candidates with the following skills: A solid understanding of Medicare and CMS regulations Strong analytical skills Customer-focused mindset Experience with the appeals and grievance process is highly valued Clinical background or experience in a healthcare setting is a plus. Excitement around (and experience leveraging) approved AI tools (ex: CoPilot) to support efficiencies in this work This fully remote role requires a 40-hour work week. We're seeking candidates who are able to work as needed possibly including some weekends

Requirements

• Associates degree or equivalent work experience required
• 2 years - Customer service and/or claims experience
• 1 year – Medicare Advantage customer service and claims experience required
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Proficient oral and written communication skills
• Proficient interpersonal and organizational skills
• Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment
• Capacity to solve problems and manage multiple assignments with critical deadlines; including analyzing claims, medical records & documents pertinent to the case review
• Knowledge of CMS regulations and guidelines related to appeals, grievances and complaints

Nice To Haves

• Experience with the appeals and grievance process is highly valued
• Clinical background or experience in a healthcare setting is a plus.
• Excitement around (and experience leveraging) approved AI tools (ex: CoPilot) to support efficiencies in this work

Responsibilities

• Documenting and investigating the substance of the appeal, grievance, or complaint and the action taken, including any aspects of clinical care or reimbursement issues involved.
• Notifying involved parties of the outcome of a review (i.e. approval and/or denial of an appeal, grievance or complaint), including CMS and the member or appellant of the resolution of all CMS complaints in the appropriate timeframes as set forth by the applicable regulatory rules and regulations.
• Providing excellent customer services to members, provider and CMS.
• Maintaining knowledge of and adhering to CMS regulations and guidelines affecting the appeal/grievance/complaint process.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree