Note: The job is a remote job and is open to candidates in USA. reputed company is a company focused on quality management in healthcare, and they are seeking a Grievance and Appeals Analyst. reputed company role involves responding to grievances and appeals, ensuring compliance with regulations, and analyzing data to identify trends and solutions.

Responsibilities

• Responsible for receiving and monitoring information related to provider quality assurance issues including but not limited to grievances, quality of care concerns, and/or appeals
• Works to ensure comprehensive quality assurance information is available to agency staff/departments as needed
• Leverages critical thinking to identify trends within grievance, appeal, and other clinical data sources
• Creates actionable analysis and identifies the most effective party to address any identified issues with minimal supervision
• Works independently to mediate complex relationships between multiple external and internal stakeholder so that all parties are satisfied with identified resolutions
• Ensures resolutions of issues related to member experiences are compliant with local, state and reputed company
• Utilizes various internal and external data platforms to perform a thorough analysis of issues related to member experiences
• Utilizes professional communication skills to provide information to internal and external stakeholders verbally and in writing
• Monitors timelines to ensure that quality assurance issues and reports are reviewed in a timely manner as to be most effective for agency processes
• Uses analytical skills to define recommendations and improve practices
• Creates and presents analyses of short-term studies using clear and direct language to explain trends and areas of opportunity to management and other staff; Trains internal and external customers on quality assurance reporting requirements
• Reviews policies and procedures and makes recommendations for changes/edits in alignment with current guidelines and requirements
• Collaborates with internal staff to ensure all relevant information is available for consideration
• Prepares and ensures timely mailing of receipt of appeal and outcome notification letter to the individuals/ guardians and providers based on the most current formats and timeline requirements
• Tracked appeal requests and assignment of the local reconsideration review process through resolution
• Maintains all denial and appeals reputed company in a an accessible manner
• Participates in the development of internal training on Denial and Appeals as determined by the internal and external quality reviews
• Aids legal counsel in ensuring fluent communication and exchange of documents are effectively made between all parties involved in the appeals process
• Ensures Alliance staff are prepared for mediation and hearings by preparing and organizing all legal and clinical documents for 2nd level appeals
• Assists in the discovery process with Alliance’s legal department and draft Office of Administrative Hearings (OAH) documents
• Schedules mediation hearings and documents the process and outcomes
• Provide training and technical assistance to staff regarding Due Process rules
• Reviews first level appeal decisions to ensure first level appeal reviewers are applying service definition and clinical guidelines when making appeal determinations
• Writes, edits, and/or coordinates the preparation of correspondence, reports, or other printed reputed company according to well established standards or readily available
• Performs other related duties as assigned

Skills

• A minimum of a Bachelor's degree from reputed company college or university with a reputed company in reputed company, public health, psychology, sociology, public administration, management information reputed company, statistics, or a related field
• A minimum of two years working human services/reputed company post bachelor's degree
• A minimum of two years of experience analyzing data sets, interpreting and synthesizing data into a report format, and working with teams/units to integrate data information needs
• Knowledge of Federal and State regulations on Behavioral Healthcare grievances and appeals processes
• Knowledge on medical records practices and records keeping practices
• Knowledge of legal proceedings including mediation, administrative law courts, and other legal processes
• Demonstrated proficiency in personal computer use and MS Excel
• Must have good oral, written, and graphic presentation skills
• Must demonstrate understanding of data analysis and techniques
• Demonstrated ability to learn new software and user capabilities
• Ability to integrate programmatic information into required da