Sr. Complaint & Appeals Analyst-PCHP

Parkland Community Health Plan’s (PCHP’s) Senior Complaint and Appeals Analyst is responsible for intake, investigation, distribution and resolution of complaints and appeals for Medicaid including STAR, CHIP, and CHIP Perinate. Cooperates with multiple business units to obtain all information needed to assure final resolution and response. Ensures timely, customer focused acknowledgment of all complaints and appeals. Identifies and reports trends and emerging issues and recommends solutions.

Bachelor’s degree.

Five years of experience in Medicaid/CHIP/CHIP Perinate products and benefits.

Three years of experience in medical claims systems, medical management, managed care organization compliance and regulatory requirements.

Experience in provider relations, customer service and audit experience are preferred.

Experience in research and analysis of claim processing is preferred.

May have an equivalent combination of education and experience to substitute for both the education and the experience requirements.

Bilingual in English and Spanish is preferred.

Thorough knowledge of member and provider appeals, complaints policies.

Maintains composure and compassion when juggling a high volume of tasks and deadlines.

Ability to form collaborative working relationships.

Strong analytical skills focusing on accuracy and attention to detail.

Outstanding interpersonal communication skills, both verbal and written.

Ability to multi-task and use multiple computer applications at one time.

Proficient in Microsoft applications including Word, Excel, and Outlook.

Knowledge of NCQA accreditation requirements is preferred.

Experience with QNXT is highly preferred.

Collaborates with appropriate subject matter experts within another business units to effectively identify appeals and complaints in a timely and appropriate manner. Coordinates all components of appeals, complaints including final communication to member and provider for final resolution and closure.

Responsible for reviewing, identifying, distributing, and documenting all incoming State (HHSC/TDI) e-mail, and fax complaints as well as all other complaints and appeals.

Assists the Member Advocate in creating and maintaining an audit mechanism to measure the quality of work for both internal and external complaints and appeals work processes.

Researches PCHP benefits and processes to determine accuracy and appropriateness of benefit and administrative denial or reduction.

Researches claim processing logic to verify accuracy of claim payment, member eligibility data, billing and payment status, as part of the appeal and complaint process.

Serves as a technical resource to colleagues regarding appeals, complaints issues, and similar situations requiring a higher level of expertise.

Identifies trends and emerging issues regarding appropriate release and/or utilization of e-mail or fax information. Reports and gives input on potential solutions.

Responsible for monitoring and resolving OnVida communication system tasks.

Other duties as assigned.

1. Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
2. Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
3. Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.