Appeals Analyst Overview • The Appeals Analyst role involves analyzing and resolving appeals, coding disputes, and grievances with adherence to regulatory guidelines. • Interpret and explain health plan benefits, policies, and medical terminology to members and providers. • Utilize judgment to make decisions aligned with organizational policies and ensure business continuity. • Prepare documentation and position statements for external reviews and consultations. • Monitor daily reports to ensure compliance and service timeliness. • Collaborate with Medical Directors for clinical appeals and grievances decisions. • Ensure work quality and efficiency to meet accreditation standards and organizational policies. • Document investigations, findings, and actions in applicable systems comprehensively. Appeals Analyst Key Responsibilities & Duties • Analyze and resolve appeals, grievances, and coding disputes from various stakeholders. • Interpret health plan benefits and policies for members and providers. • Prepare documentation for external reviews and benefit panels. • Monitor compliance and service timeliness through daily reporting. • Collaborate with Medical Directors for clinical information gathering and decisions. • Ensure adherence to state and federal accreditation standards. • Document investigation findings and actions in organizational systems. • Act decisively to maintain business continuity and compliance. Appeals Analyst Job Requirements • Bachelor’s degree required; in lieu of degree, 5 years of related experience. • Minimum of 3 years of related experience; 5 years preferred. • Certified Professional Coder certification required within 1 year for coding disputes. • Strong knowledge of regulatory and accreditation guidelines (CMS, ERISA, NCQA). • Proficiency in medical terminology and health plan policies. • Ability to document findings and actions comprehensively in organizational systems. • Excellent analytical and decision-making skills. • Familiarity with appeals, grievances, and coding dispute resolution processes.