3 Openings
Taguig
Role description
Job Summary:
Acting in a quality assurance capacity, Appeals and Grievances Analysts are responsible for processing appeals and grievances by evaluating the organization's initial decisions against CMS guidelines and enrollee benefits, by preparing a detailed summary statement of the appeal or grievance case, including research to substantiate the appeal or grievance, and for the end-to-end processing of each case. All appeals and grievance cases must be documented in the highest quality possible, ensuring the appeals and grievances are performed timely, accurately and in accordance with CMS Grievance and Appeals regulations.
Responsibilities:
Follow Grievances and Appeals processes and systems to ensure data quality to support UST HealthProof's quality, production and financial goals
Investigate and thoroughly document findings on all grievances and appeals
Prepare Appeal case recommendations for initial review process
Coordinate appropriate reviewer assignment for Appeals and Grievance cases
Responsible to move Appeals and Grievances through each review level to ensure timely completion
Drive operational excellence into all processes and departmental interactions based on CMS and UST HealthProof's requirements
Bring to management's attention any system or process issues determined during the investigation of the appeal or grievance
Coordinate effectively with the Information technology department on upgrades/fixes/changes
Participate in the departmental audit/oversight program that focuses on continuous quality improvement
Participate in compliance committees to help continuously improve initial decision making
Requirements:
Bachelor's degree in business administration, Economics, Health Care, Information Systems, Statistics or other related field is required. Master's Degree in related field preferred. Relevant combination of education and experience may be considered in lieu of degree
Certification or progress toward certification is highly preferred and encouraged
Experience in a grievance and appeals environment, including experience with the grievance and appeals regulations per CMS
Experience in medical benefits and health care industry regulations and processes; experience in claims, authorizations, and Medicare Advantage plans
Experience working in or with Medicare Advantage plans, or Independent Review Entities
Experience with CMS regulations regarding Medicare Advantage, and Medicare Advantage plans appeals and grievance processes
Knowledge in claims, authorizations, and Medicare Advantage plans
Proven problem-solving skills and ability to translate knowledge to corporate departments
Strong communication skills are required to understand, interpret, and communicate ideas
Strong analytical, organizational, planning, and problem-solving skills
Ability to effectively interface with employees at all levels
Ability to define problems, collect data, establish facts, and draw valid conclusions
Demonstrated track record of generating results and having an impact on organizations
Strong focus and drive to serve the customer
Ability to work in a high paced environment
Ability to consistently meet deadlines
Skills
Healthcare,Medical Management,Quality Assurance
About UST
UST is a global digital transformation solutions provider. For more than 20 years, UST has worked side by side with the world's best companies to make a real impact through transformation. Powered by technology, inspired by people and led by purpose, UST partners with their clients from design to operation. With deep domain expertise and a future-proof philosophy, UST embeds innovation and agility into their clients organizations. With over 30,000 employees in 30 countries, UST builds for boundless impacttouching billions of lives in the process.
