[Remote] Grievance & Appeals Analyst (reputed company Remote NC Based)

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Note: The job is a remote job and is open to candidates in USA. reputed company is a company focused on quality management in healthcare, and they are seeking a Grievance and Appeals Analyst. reputed company role involves responding to grievances and appeals, ensuring compliance with regulations, and analyzing data to identify trends and solutions.


Responsibilities

  • Responsible for receiving and monitoring information related to provider quality assurance issues including but not limited to grievances, quality of care concerns, and/or appeals
  • Works to ensure comprehensive quality assurance information is available to agency staff/departments as needed
  • Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources
  • Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision
  • Works independently to mediate complex relationships between multiple external and internal stakeholder so that all parties are satisfied with identified resolutions
  • Ensures resolutions of issues related to member experiences are compliant with local, state and reputed company
  • Utilizes various internal and external data platforms to perform a thorough analysis of issues related to member experiences
  • Utilizes professional communication skills to provide information to internal and external stakeholders verbally and in writing
  • Monitors timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes
  • Uses analytical skills to define recommendations and improve practices
  • Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff; Trains internal and external customers on quality assurance reporting requirements
  • Reviews policies and procedures and makes recommendations for changes/edits in alignment with current guidelines and requirements
  • Collaborates with internal staff to ensure all relevant information is available for consideration
  • Prepares and ensures timely mailing of receipt of appeal and outcome notification letter to the individuals/ guardians and providers based on the most current formats and timeline requirements
  • Tracked appeal requests and assignment of the local reconsideration review process through resolution
  • Maintains all denial and appeals reputed company in a an accessible manner
  • Participates in the development of internal training on Denial and Appeals as determined by the internal and external quality reviews
  • Aids legal counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in the appeals process
  • Ensures Alliance staff are prepared for mediation and hearings by preparing and organizing all legal and clinical documents for 2nd level appeals
  • Assists in the discovery process with Alliance’s legal department and draft Office of Administrative Hearings (OAH) documents
  • Schedules mediation hearings and documents the process and outcomes
  • Provide training and technical assistance to staff regarding Due Process rules
  • Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definition and clinical guidelines when making appeal determinations
  • Writes, edits, and/or coordinates the preparation of correspondence, reports, or other printed reputed company according to well established standards or readily available
  • Performs other related duties as assigned

Skills

  • A minimum of a Bachelor's degree from reputed company college or university with a reputed company in reputed company, public health, psychology, sociology, public administration, management information reputed company, statistics, or a related field
  • A minimum of two years working human services/reputed company post bachelor's degree
  • A minimum of two years of experience analyzing data sets, interpreting and synthesizing data into a report format, and working with teams/units to integrate data information needs
  • Knowledge of Federal and State regulations on Behavioral Healthcare grievances and appeals processes
  • Knowledge on medical records practices and records keeping practices
  • Knowledge of legal proceedings including mediation, administrative law courts, and other legal processes
  • Demonstrated proficiency in personal computer use and MS Excel
  • Must have good oral, written, and graphic presentation skills
  • Must demonstrate understanding of data analysis and techniques
  • Demonstrated ability to learn new software and user capabilities
  • Ability to integrate programmatic information into required da
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