Appeals and Grievance Analyst- Senior Care Division

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 Job 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.

Job Qualifications Education

• Associates degree or equivalent work experience required

Experience

• 2 years - Customer service and/or claims experience
• 1 year – Medicare Advantage customer service and claims experience required

SkillsCertifications

• 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

Number of Openings Available 1Worker Type: EmployeeCompany: BCBST BlueCross BlueShield of Tennessee, Inc. Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means. Apply tot his job Apply To this Job