Who We Are Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are. We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health.

Job Summary Under the general direction of the Member Appeals and Grievance Supervisor the Appeals and Grievance Analyst is responsible per State and Federal regulations for the professional and compliant management and coordination of assigned member appeals and grievance (complaints) received by Point32Health. This individual works collaboratively with the member and/or the member's authorized representative and must demonstrate superior customer service and benefit interpretation skills in all interactions. This individual prepares cases for presentation, discussion, review, and final disposition at the Member Appeals Committee (MAC) and Member Appeals Reconsideration Committee (MARC) and participates in the Appeals Committee discussion when needed. Responsibilities include development and coordination of all written documentation and correspondence to the member outlining final disposition of the member's appeal or grievance providing further appeal options as appropriate. Analysts routinely interact with members, providers, and other internal and external constituents about highly escalated issues.

Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. The employee must have the ability to learn and apply Point32Health's policies and remain compliant with frequently changing State and Federal regulatory requirements and have the judgment to seek out guidance as needed. The Analyst is responsible for the accurate coordination, efficient administration and resolution of member appeals and member grievances submitted by Point32Health members for all lines of business.

Job Description

• Act as a member advocate; clearly communicating the appeal and grievance process and procedures both orally and in writing.
• Manage assigned member appeals and grievance cases from documentation, to investigation, and through resolution, ensuring the final disposition of a member's appeal or grievance is compliant with the regulatory requirements set-forth by NCQA (National Committee for Quality Assurance), DOI (Dept of Insurance), CMS, DOL and any state or federal specific regulations that apply.
• Review and interpret product and benefit designs for all lines of business according to State and Federal regulatory requirements
• Manage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customers

Qualifications - What You Need To Perform The Job Certification and Licensure Education

• Required (minimum): Associate's Degree or equivalent experience in health care, conflict resolution or related field
• Preferred: Bachelors Degree in related field

Experience

• Required (minimum): 2-4 years' experience as a customer service or member services representative in health care or insurance
• Preferred: 2 years' Appeals and Grievance experience

Skill Requirements

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel) :

• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Weekend Coverage may be required on a rotating basis as regulated for line of business.
• May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.

Disclaimer The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range $22.92 -$34.38

Compensation & Total Rewards Overview The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company's sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

We welcome all All applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Scam Alert : Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org

PDN-a05c1a77-4c17-43d8-bee3-f9a406ce4d8a