Essential Duties and Responsibilities

Primary duties may include, but are not limited to:

• Reviews, analyzes, and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies, and claims events requiring adaptation of written responses in clear, understandable language.
• Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review.
• The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews.
• The file review components of the URAC and NCQA accreditations must pass items to achieve the accreditation.
• Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination.
• Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information.
• The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Requirements:

• HS diploma or GED
• Minimum of 3 years' experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background.

Minimum Qualifications (Education, Experience, Skills)

• Demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, the company's internal business processes, and internal local technology is strongly preferred.
• For URAC accredited areas, the following professional competencies apply:
• Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Ability to commute/relocate:

• Indianapolis, IN 46278: Reliably commute or planning to relocate before starting work (Required)

Work Location: One location/Opportunity to work remote partially.

Benefits:

• 401(k)
• Dental Insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Education:

• High school or equivalent (Required)

Experience:

• grievances and appeal 3 years of experience (Required)