Appeals Analyst Job Description

Appeals Analyst Job Description

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Appeals analyst provides consulting expertise based on area of specialization, such as managed care, program integrity, care management, claims processing, etc.

Appeals Analyst Duties & Responsibilities

To write an effective appeals analyst job description, begin by listing detailed duties, responsibilities and expectations. We have included appeals analyst job description templates that you can modify and use.

Sample responsibilities for this position include:

Provide operational support by reviewing, researching, investigating and analyzing findings related to Appeals and Grievances quality reviews
Provide feedback, coaching and training to team members regarding review findings and remediation opportunities
Analyze and identify trends and provide feedback and reports to reduce errors and improve A&G processes and performance
Develop and maintain process documentation and engage with BPQM leadership to implement remediation and training plans
Analyze information and utilize resources to build recommendations to reduce errors and improve process performance
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, and completion of the respective written communication documents to convey the determination
The file review components of the URAC and NCQA accreditations are “must pass” items to achieve the accreditation
The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments

Appeals Analyst Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Appeals Analyst

List any licenses or certifications required by the position: LPN, CCM

Education for Appeals Analyst

Typically a job would require a certain level of education.

Employers hiring for the appeals analyst job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Associates, Education, Health Care, Accounting, Conflict Resolution, Law, Nursing, Medical, Business, Business/Administration

Skills for Appeals Analyst

Desired skills for appeals analyst include:

Claims processing methodologies
Company products
Multiple processing systems and workflows
Medical terminology
HMOs
IPAs
MSOs
Managed care contracts and compliance
Networks
Health care professional services billing and reimbursement environment

Desired experience for appeals analyst includes:

Experience with Tricare Operational regulations, COMAR, ERISA and claims processing and/or billing guidelines
Excellent interpersonal skills and attitude to effectively project a positive image of managed care programs by being courteous, helpful, friendly, and professional in relationships with enrollees, families and co-workers
Obtaining cooperation from these other areas requires an awareness of their functions and necessitates the development and maintenance of relationships to include instilling an awareness of our customer expectations and responses
Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information
Identify opportunities for improvement and any provide support and assistance to G & A Analyst I associates as needed
Provide Appeals and Grievances support by reviewing, researching, investigating, auditing Appeals and Grievances

Appeals Analyst Examples

1

Appeals Analyst Job Description

Job Description Example
Our company is searching for experienced candidates for the position of appeals analyst. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for appeals analyst
  • 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 response in clear, understandable language
  • Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination
  • Represents the highest level of expertise that is required to respond to regulators, media inquiries, member and provider issues escalated to the Executive Leadership Team (ELT) and regulatory agencies
  • Researches and makes determinations on complex appeals or grievances that come from a variety of sources including the state/federal regulators, members, media, attorneys representing members and inquiries received from any of these sources
  • This includes reviewing and extrapolating member Evidence of Coverage language for interpretation where ambiguity may exists and initiates a recommendation to Contracts and/or Legal
  • Works with the Legal Department on various types of cases such as pleadings received from the various regulators, actions and violations and with Public Relations and Government Relations on research and resolution of media issues
  • Create, review, and/or edit Standard Operating Procedures, Job Aids, Bulletins and 411 Alerts to provide clear and concise guidance for Community and State (C&S) Appeals and Grievance (A&G) Triage and Resolution Analysts
  • Collaborate with internal business partners such as the Triage SME’s, Supervisors, Managers, Resolution Analyst Teams, Account managers, and Quality to ensure business goals are met
  • Consult with SMEs across all lines of business to create or revise documentation for completeness and consistency
  • Ensure verbiage is easy to comprehend for all populations and experience levels
Qualifications for appeals analyst
  • 4+ years of experience with Employer and Individual (ie, Commercial Insurance) pre-service and claim appeals case processing, for both pharmacy and medical benefits, working for a commercial health plan (This experience should include reviewing medical and pharmacy appeals received by a commercial health insurance organization)
  • 1+ year of proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
  • 2+ years of experience with Microsoft Excel (Ability to create simple graphs, sort and arrange information)
  • 1+ years of experience researching and/or processing claims using the COSMOS claims platform
  • 5+ years of Medicare claims processing experience
  • 3+ years of Medicare claims research and adjustment experience
2

Appeals Analyst Job Description

Job Description Example
Our innovative and growing company is looking for an appeals analyst. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for appeals analyst
  • Utilize best practices for writing technical documents when creating SOPs and other documentation
  • Work with business partners to standardize content where possible
  • Maintain records detailing SOP revisions, including specific content revised
  • Respond to escalated requests in a timely manner
  • Work special projects as assigned by leadership team
  • As such, the analyst will strictly follow department guidelines and tools to conduct their reviews
  • No work-at-home available
  • Analyzes hospital claims to identify contractual underpayments or billing errors
  • Resolves underpaid claims from various payer products including HMO, PPO, Medicaid, Medicare and Workers' Compensation
  • Articulates contract provisions to representatives from healthcare payer companies and government agencies
Qualifications for appeals analyst
  • Knowledge of Medicare and internal UHC claims processing requirements
  • 4+ years of experience with Medicare Advantage Part C or Part D Appeals and Grievance case processing experience working for a Medicare Advantage Health Plan
  • Experience and knowledge of Medicare appeals (medical and pharmacy) and grievances rules and regulations
  • 1+ years of proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
  • 2+ years of current CPT/HCPCS coding experience (entering codes, auditing )
  • Must possess an unrestricted nursing license (RN/LVN/LPN) or a current certified coder (CPC/CCS/RHIT )
3

Appeals Analyst Job Description

Job Description Example
Our growing company is hiring for an appeals analyst. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for appeals analyst
  • Performs appropriate follow up with Payer and gains commitment for payment
  • Escalates Payer lack of response and/or lack of payment within Payer organization as appropriate
  • Serves as a subject matter expert in Payer contract dispute resolution process
  • Serving as a Subject Matter Expert of the Grievance and Appeals process and represents the highest level of expertise that is required to respond to regulators, media inquiries, member and provider issues escalated to the Executive Leadership Team (ELT) and regulatory agencies
  • Collaborate and work with Member Experience and other Intra Departmental areas to improve processes and correct deficiencies
  • Participate in research and validation of Audits including Regulatory, Accreditation, Group among other Audit requests as needed
  • Will participate in system testing as needed for new systems, updates and/or enhancements
  • Training of new systems and processes as required
  • Responsible for supporting the processing of Appeals and Grievances for multiple lines of business, including reviewing, analyzing and processing complex pre-service and post-service grievances and appeals requests in the Enterprise Grievance and Appeals Department and the completion of written communication documents to convey the determination
  • Perform and validate claim level denial and appeal inventory
Qualifications for appeals analyst
  • Stays current with press releases, emails, and other forms of communications relaying initiatives, contracting issues, Plan wide concerns
  • Undergraduate degree or high school diploma/GED
  • 2+ year experience as a Resolution Analyst processing appeals and grievances using ETS for Community & State for both member and provider
  • 2+ years processing both Medical and Hospital claims using CSP Facets
  • Entry level experience writing new operating procedures from process flow maps, requirement descriptions, or existing process guidelines
  • Intermediate to advanced skills with MS Word, Excel, Outlook, SharePoint(TeamTrack), and PowerPoint
4

Appeals Analyst Job Description

Job Description Example
Our growing company is looking to fill the role of appeals analyst. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for appeals analyst
  • Communicate clearly, such as telephonically, online or via payment package processes to both internal and external parties
  • Gain commitment, when required, for payment through concise and factual collection techniques
  • Facilitate correction of non-payment related discrepancies through I-plan changes or coordination with other departments as needed
  • Escalate accounts to appropriate individuals at the payer and management as needed, including accounts with lack of timely payer response
  • Coaches, trains, and audits to ensure the team correctly 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 clinical staff for review
  • Assists in training new associates and helps manager identify need for remedial training
  • Serves as an expert on company knowledge for the team
  • Identification of process improvements consistent with compliance requirements and presentation for implementation
  • Determine and initiate appropriate appeal process tracking
  • Determines outcome of non clinical appeal decisions using judgment within set guidelines for more complex cases
Qualifications for appeals analyst
  • Demonstrate flexibility and the ability to deal well with ambiguity
  • Ability to prioritize and work independently or as part of a team
  • Ability to track assignments and communicate using TeamTrack/SharePoint, Email, and WebEx
  • Knowledge of multiple products and benefits associated with each product
  • Reviews, classifies, researches and resolves member complaints (grievances and/or appeals) and communicates resolution in writing to members or their authorized representatives in accordance with standards and requirements established by the Centers for Medicare and Medicaid
  • Researches member's covered benefits under both Medicare and Medicaid, using member utilization and medical records obtained for the purpose of critically reviewing member's complaint
5

Appeals Analyst Job Description

Job Description Example
Our company is searching for experienced candidates for the position of appeals analyst. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for appeals analyst
  • The lead may serve as a liaison between grievances & appeals and /or dental management, legal, and/or service operations and other internal departments
  • The lead may serve as an internal resource for the department and supports the department by leading assigned projects and initiatives
  • Responsibilities exclude conducting any utilization or dental management review activities which require the interpretation of clinical information
  • The associates in the grievance & appeal departments are the face and voice of the company and gather intelligence for the organization which is presented through root cause analysis
  • Administrative appeals are more varied and include membership issues, provider issues, and contractual issues, which often have clinical implications
  • Both administrative and clinical appeals dictate greater analytical and problem solving abilities working knowledge of WellPoint's organizational structure
  • Enhances and improves workflow processes for data capture
  • Continuously evaluates systems performance to identify opportunities to streamline and enhance data collection and reporting
  • Acts as main contact for outside vendors or service providers related to computer operations
  • Coordinates all system data dictionaries, upgrades, and downtime in collaboration with IT counterparts
Qualifications for appeals analyst
  • Demonstrated knowledge in the health field as acquired during three (3) years of acute care nursing experience
  • Knowledge of Interqual Milimen & Roberts or other utilization review tools
  • Coordinates with pertinent departments and treating providers to effectuate timely resolution resulting from grievance and appeals decisions made at the plan level or by independent review entities
  • Collects, analyzes and interprets grievance and appeals data
  • 2 years experience processing grievances and appeals within a managed care setting
  • Experience in customer/ member services or prior authorization within a Medicare or Medicaid environment, may substitute for one year of the minimum required experience

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