Member Appeals & Grievance Analyst – Level 2
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Job Description
Member appeals analyst resolving CMS-regulated cases for BCBST, Tennessee’s health benefit plan company. Investigating complaints, communicating outcomes, and ensuring timely regulatory compliance.
Responsibilities:
- Document and investigate the substance of appeals, grievances, or complaints and the action taken, including clinical care or reimbursement issues.
- Notify involved parties of review outcomes, including approval or denial of appeals, grievances, or complaints.
- Notify CMS and members/appellants of resolutions for CMS complaints within applicable regulatory timeframes.
- Provide excellent customer service to members, providers, and CMS.
- Maintain knowledge of and adhere to CMS regulations and guidelines affecting the appeal, grievance, and complaint process.
- Evaluate cases, determine appropriate next steps, and manage multiple priorities while meeting turnaround times.
- Use digital and AI-enabled tools responsibly to improve workflow efficiency.
Requirements:
- Associate's degree or equivalent work experience required
- 2 years of customer service and/or claims experience
- Knowledge of Medicare and CMS regulations and guidelines related to appeals, grievances, and complaints
- Proficiency in Microsoft Office, including 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 in a fast-paced environment
- Ability to solve problems and manage multiple assignments with critical deadlines
- Ability to analyze claims, medical records, and documents pertinent to case review
- Strong analytical skills and attention to detail
- Strong data entry accuracy and case management skills
- Customer-focused approach
- Experience using or enthusiasm for leveraging AI tools such as Copilot
- Required weekend coverage every weekend
- Agreement to remain in the weekend role for a minimum of 2 years after completion of all training
- Sponsorship is not available for this role
- Remote positions are unavailable to applicants residing in California, Massachusetts, New Hampshire, New Jersey, or New York
Benefits:
- Fully remote work arrangement
- 40-hour work week
- Flexibility based on business needs
- Remote-first organization
- Potential relocation assistance if residence in Chattanooga, TN is required and eligibility applies
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