Appeals and Grievance Analyst - Casual

Community Health Network of Connecticut, Inc. (CHNCT) is currently seeking an Casual/Per-Diem Appeals and Grievances Analyst.

Primary Responsibilities:

• Under the direction of the Manager and Team Lead, Appeals and Grievances, the Appeals and Grievances Analyst is responsible for clinical investigation of all aspects of the service being denied, reduced or terminated, in collaboration with CHNCT’s Chief Medical Officer, medical reviewers, and clinical consultants.
• The Appeals and Grievances Analyst attends Administrative Hearings as needed (telephonically or in-person) and collaborates with internal departments such as Care Management, Medical Management, and Provider/Member Engagement, as well as external agencies to process member and provider appeals/re-evaluations.

Tasks Performed:

• Investigates and processes member appeals, provider reevaluations, and grievances.
• Communicates with members and providers, performs case analysis, enters data in the documentation management system, generates and edits letters.
• Refers quality of care issues to Quality Management Department for tracking and follow-up.

Essential Functions:

• Conducts appeal and grievance investigations; prepares hearing summaries and reports; presents summarized information to medical reviewers; participates at Administrative Hearings; performs medical record reviews to support DSS reporting requirements; conducts chart reviews as part of CHNCT’s Quality Management and Improvement programs.

Desired Education: Two to four years post-secondary schooling

Desired Degree: Associate's degree, Bachelor's degree preferred

Desired Major: Nursing

Desired Job Experience: 3 to 5 years' clinical experience preferred

Other Qualifications: Excellent oral and written communication skills. Strong computer and keyboard skills; Highly organized, with specific attention to detail. Ability to exercise independent and sound judgement in decision making. Team player attitude essential. Managed care experience preferred. RN Nursing license must be current and unrestricted. Must hold a valid and unrestricted motor vehicle operator’s license and have reliable transportation.

Certifications Required: Active Registered Nurse License, State motor vehicle license

We are dedicated to having a workplace where everyone feels valued, respected, and empowered to succeed. We embrace a wide range of perspectives and backgrounds, ensuring fair treatment and opportunities for all employees. We value our team’s rich array of experiences and viewpoints, which contribute to our innovative and collaborative environment.