Member Appeals & Grievance Analyst-2

We are hiring a Member Appeals & Grievance Analyst at BCBST!

In this role, you will review and process appeals and grievances submitted by members and providers, ensuring timely and accurate resolution in compliance with CMS and Medicare guidelines. You will evaluate cases, determine appropriate next steps, and manage multiple priorities while meeting required turnaround times.

You’ll play a critical role in maintaining regulatory compliance, improving member experience, and supporting high-quality outcomes through detailed case analysis and effective use of digital tools to drive efficiency.

To be successful in this role, in addition to the core job requirements, you'll bring strong analytical skills, attention to detail, and a customer-focused approach. You will be a strong candidate if you have knowledge of Medicare and CMS regulations, as well as experience with the appeals and grievance process.

A clinical background or prior experience in a healthcare setting (preferred) will further strengthen your candidacy. Additionally, you should demonstrate strong data entry accuracy and case management skills, along with experience using or enthusiasm for leveraging AI tools (e.g., Copilot) to improve workflow efficiency.

We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members.

Note

• This is a fully remote role with a 40-hour work week, with flexibility required based on business needs, including required weekend coverage every weekend. An agreement to remain in the weekend role for a minimum of 2 years after completion of all training is required.
• Sponsorship is not available for this role

Job Responsibilities

• Documenting and investigating the substance of the appeal, grievance, or complaint and the action taken, including any aspects of clinical care or reimbursement issues involved.
• Notifying involved parties of the outcome of a review (i.e. approval and/or denial of an appeal, grievance or complaint), including CMS and the member or appellant of the resolution of all CMS complaints in the appropriate timeframes as set forth by the applicable regulatory rules and regulations.
• Providing excellent customer services to members, provider and CMS.
• Maintaining knowledge of and adhering to CMS regulations and guidelines affecting the appeal/grievance/complaint process.

Job Qualifications

Education

• Associates degree or equivalent work experience required

Experience

• 2 years - Customer service and/or claims experience

Skills\Certifications

• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Proficient oral and written communication skills
• Proficient interpersonal and organizational skills
• Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment
• Capacity to solve problems and manage multiple assignments with critical deadlines; including analyzing claims, medical records & documents pertinent to the case review
• Knowledge of CMS regulations and guidelines related to appeals, grievances and complaints

Number of Openings Available

Worker Type:

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Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Originally posted on Himalayas