Grievance & Appeals Analyst (Full-time Remote, North Carolina Based)

The Grievance and Appeals Analyst responds to grievances and appeals to ensure the resolutions are consistent with organizational policies and procedures and which are compliant with state and federal guidelines and also ensures due process rights. The Analyst synthesizes and analyzes all available data which may contain multiple issues and may require coordination of responses from multiple business units. The Analyst ensures timely, customer focused responses to complaints and appeals, identifies trends and emerging issues, reports and recommends solutions. Works with internal and external customers to gather and verify information related to consumer safety and provider compliance. Identifies critical issues and triages issues appropriately to ensure that urgent member needs are met expediently. Communicates trends and actionable analysis to appropriate parties in a timely manner.

This is a full-time remote position. The successful candidate must reside in North Carolina and be willing to come onsite for meetings at the Alliance office as needed.

Responsibilities & Duties

Management of General Functions

•  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 federal regulations
• 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

Management of Grievances

• 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 …