“Making Healthcare Right. Together.” is the cornerstone of all we do. Our vision is through powerful relationships with Care Partners, we help all people live healthy and brighter lives. To successfully achieve our mission and vision as we operate in a dynamic health care environment, we expect Bright employees to embody and uphold our core values in work and interactions, both internal and external: be brave, be brilliant, be accountable, be inclusive, and be collaborative.

ABOUT THE ROLE

The Senior Appeals and Grievances Analyst ensures 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 highly complex cases, accurate and timely documentation of case actions, and assist in the oversight of delegates responsible for appeals and grievances functions. 

YOUR RESPONSIBILITIES

• Reviews, researches and directs highly complex 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
• Participates in and/or leads audits, partners with analytics and compliance to analyze and finalize data sets
• Responsible for processing of all CTM’s and DOI cases. Ensure timeliness and accuracy of correspondence to regulatory entity
• Monitor all incoming appeal and grievance channels including mail, fax and phone
• Prepares and distributes reports of weekly, monthly A&G metrics to leadership
• Escalate at risk cases to management.

EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE

• Highschool Diploma or GED required; Bachelor’s degree preferred
• Five (5) or more years of experience in Health Plan Appeals & Grievances or Customer Service required
• Ability to read, write and converse fluently in Spanish is 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

ABOUT US

At Bright Health, we brought together the brightest minds from the health care industry and consumer technology, and together we created Bright Health: a new, brighter approach to healthcare, built for individuals. Our plans are easy to manage, personalized, and more affordable, giving people the quality care they deserve. Through our exclusive care partnerships with leading health systems in local communities, we are reshaping how people and physicians achieve better health together.

We’re Making Healthcare Right. Together. 

We've won some fun awards like Modern Healthcare and Forbes, etc. But more than anything, we're a group of people who are really dedicated to our mission in healthcare. Come join our team!

As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of Bright Health, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

BRIGHT ON!