Who We ArePoint32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click .Job SummaryUnder the general direction of the Member Appeals and Grievance Supervisor the Member 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.Key Responsibilities/Duties - what you will be doingAct 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, DOI, 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 requirementsManage the collection of documents and records (medical, claims, administrative) needed to fully research the appeal or complaint request with both internal and external customersConsult with subject matter experts as necessary to gather information required for appropriate resolution of the matter presented.Make recommendations on appeal decisions based on the member's benefits and individual circumstances presented.Qualifications - what you need to perform the jobEDUCATION, CERTIFICATION AND LICENSURE:Associates Degree or equivalent experience in health care, conflict resolution or related fieldEXPERIENCE (minimum years required):3-5 years health care or insurance experienceHealth care benefit and regulatory knowledge preferredKnowledge of insurance products, policies and procedures preferred.SKILL REQUIREMENTS:Demonst