SCOPE OF ROLE

The Appeals and Grievances Analyst position will ensure that Bright Health responds to complaints, grievances, and appeals in a timely, professional, and customer-focused manner, and completed according to state and federal regulatory standards. This position will be responsible for resolution of assigned cases, accurate and timely documentation of case actions, and assist in the oversight of delegates responsible for appeals and grievances functions.

ROLE RESPONSIBILITIES

The Appeals and Grievances Analyst description is intended to point out major responsibilities within the role, but it is not limited to these items.

• Reviews, researches and directs complaints, grievances and appeal cases to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required timeframes are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language. Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
• Maintains grievance and appeal case files and include necessary information to log incoming correspondences, tracking dispositions, and maintaining timeliness of resolution as required by state and federal mandates.
• Ensures that all information to members, providers, other parties-to-a-complaint, and other appropriate persons is accurate, consistent, and customer sensitive.
• Participates in internal committee and interdisciplinary meetings, reporting recent activity and analysis of trends, and makes recommendations for problem resolution and performance improvement
• Monitor all incoming appeal and grievance channels including mail, fax and phone
• Other duties and responsibilities as assigned.

SUPERVISORY RESPONSIBILITIES

• This position does not have supervisor responsibilities.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Bachelor’s degree or equivalent work experience preferred
• Three (3) or more years of experience in health plan operations setting required, preferably in Appeals & Grievances or Health Care Customer Service
• Two (2) or more years of MA experience preferred

PROFESSIONAL COMPETENCIES

• Detail oriented
• Thrive in fast-paced environments and have a passion for extemporary customer service and resolving conflicts
• Self-directed, able to prioritize and takes ownership in projects, cases, and workgroups

BEHAVIORAL AND LEADERSHIP NORMS

• Bright Values: Lives the Bright Values.  Is focused on bravery needed to develop a variety skills. Not afraid to ask questions or take risks. Focuses on purposeful planning and objective setting. Focuses on the team’s successes, and how to support that effort.
• Collaboration:  Is an effective collaborator that works well with the functional team and others in the organization to align on timelines and effective delivery of a project or task. Is solution oriented and works on generating input from multiple constituents and driving the team to a solution. Is able to work with different personality types and teammates to overcome differences in opinion and thought to achieve common company goals.
• Delivers Results: Is results oriented. Focuses on results and the best and most efficient avenue for achieving results. Works with manager or appropriate liaison in the organization to work through goal setting and milestone development to ensure timely and high quality work product. Achieves strong results within functional area. Is focused on managing against a predetermined set of objectives, and creates and follows process.
• Exhibits Curiosity: Focuses on learning about the business at large. Seeks to understand how they can drive the business forward and how the bigger picture works. Actively participates in his/her own career development.
• Multi-tasking:  Balances multiple projects and initiatives at any given time. Alongside manager or appropriate Bright teammate, re-evaluates priorities based on changing company needs to understand what must be done today. Consistently meets deadlines.
• Upward Management: While balancing multiple initiatives, successfully manages expectations with appropriate project owner about capacity, challenges and barriers to success. Is not afraid to ask for help, guidance or feedback.

LICENSURES AND CERTIFICATIONS

• No licensures and/or certifications are required for this role.

WORK ENVIRONMENT

• The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Some travel may be required.