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Grievance and Appeals Reporting Analyst, Fairfield, CA


Organization: Partnership HealthPlan of California
Category: Professional
Location: Fairfield, CA
Date Job Posted: July 1, 2022
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Grievance and Appeals Reporting Analyst

US-CA-Fairfield

Job ID 2022-2214 FLSA Status Exempt

Overview

The Grievance & Appeals Reporting Analyst plays a vital role in root-cause analysis of case trends and satisfying Partnership HealthPlan’s reporting obligations to internal and external stakeholders. Responsible for ongoing development and implementation of quantitative data analysis and reporting capabilities required to meet NCQA requirements, DHCS-mandated reports, and departmental strategic goals. Serves as an expert in Grievance & Appeals data. Presents findings to stakeholders to advance Partnership HealthPlan’s operational excellence and member experience. Will support the migration to a new Grievance & Appeals operating platform.

Responsibilities

  • Develops quantitative analysis and programs reports to ensure Grievance & Appeals achieves NCQA requirements, DHCS-mandates, and departmental strategic goals
  • Responsible for the creation and submission of DHCS-mandated reports at designated frequencies
  • Using data, identifies systemic issues that trigger member dissatisfaction. Makes recommendations that improve operational excellence, member experience, and/or clinical practice to reduce grievance and/or appeals trends
  • Analyzes and formalizes use of data for new Reporting Interest (RI) categories
  • Analyzes casework data and develops additional criteria for case-level identifiers that will further identify systemic issues
  • Defines and educates Grievance & Appeal staff on best practices for case-level reporting
  • Creates ad hoc reports upon requests
  • Establishes an ongoing process to maintain quality data and define quality audit processes
  • Creates and maintains the audit database of closed cases.
  • Runs monthly Audit and Performance reports for Grievance & Appeals leadership
  • Provides data to leadership to support committee presentations
  • Contributor to the Business Requirements Document (BRD), supporting the transition to a new operating platform.
  • Performs UAT. Submits IT Tickets as needed for Everest malfunctions or new development requests.
  • Learns and retains business knowledge of Grievance & Appeals casework and departmental procedures.
  • Knowledge of or has the aptitude to learn Microsoft Access, Advanced Excel, Microsoft SQL Server, Everest, Tableau.
  • Leads projects or other activities as assigned

Qualifications

Education and Experience

Bachelor’s degree or higher in Computer Science, Statistics, Quality Control, Quality Assurance, or related field preferred. Two (2) years quality administration related activities.

Special Skills, Licenses and Certifications

Demonstrated aptitude for acquiring and applying technical skills in data analysis, reporting, and data systems. Critical thinker. Organized. Good oral and written communication skills. Strong analytical skills including knowledge of statistics. Excellent interpersonal skills. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Knowledge of MS Excel, Access, SQL, Everest, Tableau and other analytic software. Demonstrated aptitude for acquiring new technical skills in a data quality environment. Familiar with quality measurement and healthcare data. Ability to communicate technical concepts with both technical and non- technical individuals. Detail-oriented with good organizational and project management skills to work on multiple projects simultaneously within established time frames. Works well under pressure and maintains a professional composure when interacting with all stakeholders.

Work Environment And Physical Demands

Standard cubicle within a shared common area. Ability to use a computer with standard software packages. More than 75% of work time is spent in front of a computer monitor. When required, ability to move, carry, or lift objects weighing up to 25 lbs.

All HealthPlan employees are expected to:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

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