Senior Analyst, Complaints & Appeals (Pre-service) - Remote

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Job Summary:

The Sr. Analyst, Complaints & Appeals is responsible for performing quality reviews and audits of appeals, complaints, and grievance resolutions and root cause analysis to determine if pre-service cases were handled in accordance with CMS, state and/or federal guidelines and regulations and ensure member and provider experience. Prepares information on audit findings, settles disputes, and provides insights on data, potential audit risks, training, process, and program updates for Medicare, Commercial and other applicable Line of Businesses. The role develops reports, dashboards, and key performance indicators to support business decision-making and regulatory compliance. The analyst collaborates with cross-functional stakeholders to investigate issues, conduct root cause analyses, implement corrective actions, and improve operational effectiveness. The position requires strong analytical, problem-solving, communication, stakeholder management, and decision-making skills and supports multiple projects within a fast-paced healthcare environment.

Primary Job Duties & Responsibilities:

Perform quality reviews and audits of grievance and appeal resolutions to determine compliance with CMS, state, and federal regulations and ensure a consistent member experience.

Conduct root cause analysis, identified trends, analyzed operational data, and developed recommendations to reduce complaint, grievance, and appeal drivers.

Analyze complaint, appeal, overturn, and operational performance data to identify pre-service trends impacting customer and provider experience, and business performance.

Lead root cause analysis and governance activities for complaint and appeal issues, including issue identification, validation, corrective action planning, remediation tracking, and development of findings and recommendations to support leadership decision-making, operational improvements, and sustainable resolution of recurring issues.

Develop and maintain process documentation, job aids, governance materials, and operational guidance while serving as a subject matter expert, providing analytical support, facilitating knowledge sharing, and contributing to training and continuous improvement initiatives that enhance complaint and appeal operations.

Prepare reports, dashboards, presentations, and leadership summaries to communicate audit findings, operational risks, trend analysis, and process improvement opportunities.

Evaluate audit findings and provided guidance regarding corrective actions necessary to achieve departmental quality objectives and regulatory requirements.

Support governance activities by validating root cause findings, monitoring remediation efforts, and evaluating the effectiveness of corrective actions.

Serve as a subject matter expert on quality standards, regulatory requirements, operational processes, and performance measurement.

Identify process gaps, operational defects, and compliance risks and developed recommendations to improve quality performance, administrative efficiency, and customer experience.

Partner with cross-functional teams including Operations, Compliance, Clinical, Product, and Technology to improve resolution quality, operational processes, work instructions, and member experience.

Develop actionable insights from audit reviews, complaint and appeal trends, and root cause analyses to support leadership decision-making, governance reviews, and continuous improvement initiatives.

Support projects focused on process optimization, reporting enhancements, regulatory compliance, operational effectiveness, and reduction of recurring complaint and appeal drivers.

Required Qualifications:

• 3-5 years of experience in healthcare operations, complaints and appeals, analytics, quality, compliance, governance, risk management, or related functions.

• Strong analytical, problem-solving, and decision-making skills.

• Experience conducting trend analysis, root cause analysis, operational reviews, and process improvement initiatives.

• Experience developing reports, dashboards, and executive-level presentations.

• Strong written and verbal communication skills.

• Demonstrated ability to collaborate across multiple business functions and influence stakeholders.

• Advanced proficiency with Microsoft Excel, Microsoft PowerPoint, reporting tools, and data analysis methodologies.

Preferred Qualifications:

• Medicare Advantage, Part D, Grievance, CTM, Commercial Appeals, Provider Appeals, Utilization Management experience, Grievance experience or Appeals experience.

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