Appeals & Grievances Analyst

Appeals & Grievances Analyst

Harbor Health

POSITION OVERVIEW

We are seeking a data-minded, detail-oriented Appeals & Grievances (A&G) Analyst to monitor, analyze, and optimize our health plan complaint, grievance, and appeal operations. In this remote role, you will be the bridge between operational casework and analytical reporting supporting our Texas fully insured Individual & Family Plan (IFP/Marketplace) and large group (25+ employees) commercial products.

The A&G Analyst is responsible for tracking regulatory Turnaround Times (TAT), identifying operational bottlenecks, conducting root-cause trend analyses on member complaints, preparing audit universes, and ensuring reporting integrity across administrative platforms. Direct familiarity with health plan data and workflows is strongly preferred.

POSITION DUTIES & RESPONSIBILITIES

Regulatory Reporting & Audit Universe Management

• Extract, validate, and compile daily, weekly, monthly, and quarterly Appeals & Grievances reports to track compliance with federal and state Department of Insurance (DOI) mandates.

• Build and validate regulatory audit universes (intake logs, overturned/upheld rates, resolution letters, clinical escalations) for internal compliance reviews, DOI market conduct exams, and NCQA accreditation surveys.

• Monitor inbound pipeline aging queues and issue proactive early-warning flags to operational teams to prevent Turnaround Time (TAT) breaches on standard and expedited/urgent cases.

Root-Cause Analysis & Trend Identification

• Perform detailed trend analysis on incoming member and provider complaints to detect underlying drivers.

• Analyze overturn and upheld rates across specific service categories, benefit plans, and clinical specialties to pinpoint systemic operational friction.

• Partner with Operations, Quality, Utilization Management, and Network Management to translate analytical findings into corrective action plans and workflow improvements.

Data Quality & System Administration

• Monitor data integrity within the core grievance and appeals tracking system, identifying logging discrepancies, missing data fields, and classification errors.

• Monitor performance and escalate discrepancies or issues with delegated vendor functions that would impact operational and audit performance.

• Leverage core administrative systems to extract claims adjudication logs, member services/call center contact history, and grievance tracking data for consolidated reporting.

• Design and maintain operational dashboards with help of IT to provide leadership with clear visibility into operational production, translating complex data trends into clear, actionable summaries for leadership, and identifying risks to audit-readiness.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Required Experience & Skills

• Bachelor’s degree in Healthcare Analytics, Health Information Management, Business, Statistics, Public Health, or a related field (or equivalent operational healthcare experience).

• Minimum of 3–5 years of managed care or health plan experience, with at least 2 years focused on Appeals & Grievances, compliance reporting, or healthcare complaint analytics.

• Proven understanding of Commercial health insurance structures, including Large Group and Individual & Family Plans (ACA/Marketplace).

• Solid understanding of state and federal A&G reporting requirements, complaint taxonomies, and statutory TAT standards.

Preferred Qualifications

• Experience with AxisCore platform, querying, extracting data from, or navigating modules (claims processing, customer service/call center tracking, or complaint management).

• Experience generating and validating formal audit universes for CMS, DOI, or NCQA reviews.

• Advanced Excel/Sheets skills; experience creating dashboards and querying relational databases.

• Background in developing reporting solutions to replace manual tracking logs.

WHAT WE OFFER

• Fully remote work environment

• Competitive salary and benefits package

• Generous PTO

• 10 paid holidays

• Medical, Dental, and Vision Insurance

• 401(k) Investment Plan

• Professional development and growth opportunities

• A transparent and unique culture

• Collaborative and dynamic work environment

COMPANY OVERVIEW

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

EQUAL EMPLOYMENT OPPORTUNITY

Harbor Health is an Equal Opportunity Employer. We celebrate diversity and are committed to building an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.