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Parkland Health · 3 hours ago

Senior Complaint and Appeal Analyst- Health Plan

Dallas, TX

Full-time

Onsite

Senior Level

5+ years exp

Parkland Health is seeking a Senior Complaint and Appeal Analyst for their Community Health Plan. The role involves the intake, investigation, distribution, and resolution of complaints and appeals for Medicaid, ensuring timely and customer-focused responses while identifying trends and recommending solutions.

CommunitiesHealth CareHospitalMedicalNon ProfitWellness

Responsibilities

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

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

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

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

Qualification

Managed care experienceMedical claims systemsAnalytical skillsMicrosoft applicationsBilingual (English/Spanish)NCQA accreditation knowledgeQNXT experienceMulti-tasking abilityInterpersonal communicationCollaboration skills