Grievance & Appeal (G&A) Analyst I
Summary
Reviews and resolves dental insurance grievances and appeals, ensuring compliance with regulatory timelines and drafting professional responses to member/provider disputes.
We're looking for a Grievances & Appeals (G&A) Analyst I is responsible for the end-to-end investigation, analysis, and resolution of member, provider, and health plan partner grievances and appeals. This role ensures all cases are handled accurately, professionally, and within strict regulatory timelines while delivering a high level of service and compliance.
- Strong preference for candidates located on the East Coast.
- Availability to work one weekend day is required.
Key Responsibilities
- Investigate and resolve member, provider, and health plan partner grievances and appeals
- Review and analyze pre-service and post-service denials to identify discrepancies, errors, and appropriate resolutions
- Ensure all appeals are processed within regulatory and internal compliance guidelines
- Draft clear, professional written responses explaining decisions, benefit determinations, and claim adjudication outcomes
- Perform thorough case research, including claims, authorizations, and system data validation
- Verify accuracy of data entry, claims submission, and workflow processes to ensure proper reimbursement when applicable
- Maintain strong collaboration with cross-functional teams and external stakeholders
- Support grievance and appeal intake activities as needed
- Demonstrate accountability, adaptability, and adherence to policies, procedures, and performance standards
Required Qualifications
- Bachelor’s degree or equivalent combination of education and relevant work experience.
- 3+ years of dental industry experience
- 2+ years of administrative experience in a healthcare setting
- Strong written communication skills with the ability to draft professional correspondence for diverse audiences
- Solid verbal communication and customer service skills
- Ability to manage multiple cases and meet strict regulatory deadlines in a fast-paced environment
- Intermediate proficiency in Microsoft Word and Excel
Preferred Qualifications
- Dental insurance plan experience highly preferred
- Experience within a Quality Management or Appeals/Grievances department
- Knowledge of CMS (Medicare/Medicaid) appeals guidelines and regulatory requirements
- Familiarity with claims adjudication and benefit interpretation
Why Join Us
- Opportunity to make a direct impact on member and provider experience
- Collaborative, mission-driven culture
- Exposure to regulatory compliance and healthcare operations
- Career growth pathways within G&A