Appeals Analyst

We exist for workers and their employers -- who are the backbone of our economy.  That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.

The Appeals Analyst is primarily responsible for reviewing and responding to written appeals, complaints, and disputes submitted by members, attorneys, and the Department of Insurance in accordance with Benefit Plans, ERISA and Federal guidelines and regulations. This includes processing appeals to facilitate the accurate administration of benefits and policies, investigating and summarizing findings regarding the appeals, and compiling supporting documentation. This individual will work as an effective interface between internal and external customers and maintain good member and partner relationships.

Responsibilities Include:

• Comprehensively review and evaluate appeal requests, determining eligibility, benefits, and prior activity related to the claims, payment, or service in question.

• Conduct thorough investigations of all appeal correspondences by analyzing all the issues involved and obtaining responses and information from internal and external entities.

• Follow-up with responsible departments and delegated entities to ensure compliance.

• Monitor daily and weekly inventory to ensure internal and regulatory timeframes are met.

• Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost-saving opportunities, best practices, and performance issues.

• Prepare written responses to all member correspondences that appropriately address each complainant’s issues and are structurally accurate.

• Maintain data entry requirements for all complaints and appeals.

• Perform any other additional tasks or duties as assigned or required.

Qualifications:

Required Skills and Abilities:

• Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others.

• Must possess proven organizational, rational reasoning, ability to examine information, and problem-solving skills, with attention to detail necessary to act within complex environment.

• Ability to comprehend and produce grammatically accurate, error-free business correspondence required.

• Ability to appropriately identify urgent situations and follow the appropriate protocol.

• Requires the ability to plan, manage multiple priorities, and deliver complete, accurate, and timely results in a fast-paced office environment.

• Proficiency in MS Office applications required.

• Strong interpersonal skills, establishing rapport and working well with others.

Education and Experience:

• High School diploma or equivalent required, Associate degree preferred.

• At least one year of experience in health plan operations, health care clinical quality improvement, direct patient care, grievances and appeals, or other experience directly related to position duties and knowledge.

• Additional years of experience/training may be considered in lieu of educational requirements required.

Preferred Qualifications:

• Prior health industry and/or compliance work experience preferred.

Work Location:

• Candidates located within commuting distance of our Buffalo office will be considered for both in-person and hybrid roles. All other applicants will be considered for remote positions.

Who we are:

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.