Responsibilities
- Delivers high-level analytical, reporting, and issue resolution support across claims, customer service, enrollment and billing, and appeals and grievances functions.
- Collaborates with operational, technical, clinical, and compliance teams to assess trends, verify data scope, refine workflows, and maintain adherence to performance and regulatory requirements.
- Utilizes technical expertise in FACETS, reporting platforms, and data extraction methods to enhance processes, ensure compliance, and inform business decisions.
- Leads departmental project efforts for corporate and internal initiatives, including appeals and grievances reporting, claims process improvements, and regulatory updates.
- Provides written and verbal progress reports, identifies potential risks, conducts root cause assessments, and suggests process enhancements.
- Takes ownership of assigned department or corporate projects and ongoing maintenance tasks as required.
- Shares project status updates clearly and consistently with team members through both spoken and written communication.
- Recognizes potential project risks and develops contingency plans.
- Performs root cause investigations and identifies opportunities for operational improvement.
- Gathers and documents comprehensive business requirements for system changes, reporting needs, regulatory updates (CMS, State, NCQA), and process modifications.
- Foresees potential operational or regulatory challenges, documents resolution strategies, collaborates with stakeholders on implementation, and evaluates long-term effects on appeals, grievances, claims, and administrative processes.
- Serves as an expert in at least four functional areas such as Medicare Advantage appeals and grievances, claims processing, regulatory reporting, data validation, and performance analytics.
- Guides junior staff through informal coaching on reporting practices, appeals procedures, system usage, and documentation standards.
- Assists internal and external stakeholders by responding to inquiries and creating clear, accessible process documentation.
- Establishes effective working relationships across multiple departments including Appeals & Grievances, Claims, IT, Regulatory, and Customer Service.
- Presents analytical results, trends, and reporting outputs in a clear and understandable format.
- Organizes and leads meetings, prepares agendas and minutes, and communicates delays, risks, and impacts.
- Conducts testing for system updates, maintenance releases, and regulatory changes.
- Executes test cases, verifies configurations for appeals and claims, assesses defects for compliance and operational impact, and records outcomes.
- Demonstrates proficiency in relevant system applications and tasks, including FACETS database tables and reporting data models.
