Position Summary

The Senior Analyst, Appeals & Grievances Operations serves as the business owner and technical subject matter expert for the organization's Appeals & Grievances (A&G) technology platform, reporting environment, and regulatory data governance framework.

This role is responsible for managing A&G system vendors, developing and maintaining operational and regulatory reporting, supporting audit readiness, and driving automation and analytics initiatives that improve the efficiency, accuracy, and compliance of Appeals & Grievances operations. The analyst serves as the primary liaison between Operations, Compliance, Quality, Information Technology, Data Analytics, Regulatory Affairs, and external vendors to ensure data integrity, regulatory compliance, and actionable business intelligence.

The ideal candidate combines deep healthcare regulatory knowledge with advanced analytics and technology expertise to support Medicare, Medicaid, Commercial, and Exchange Appeals & Grievances programs. The role requires strong understanding of CMS, NCQA, federal, and state regulatory requirements as well as the ability to translate those requirements into reporting solutions, dashboards, monitoring tools, audit universes, system enhancements, and workflows.

Primary Responsibilities

System Ownership & Vendor Management

·       Serve as the primary business owner for the Appeals & Grievances platform and supporting technologies.

·       Develop and maintain strategic relationships with software vendors, implementation partners, and delegated technology providers.

·       Lead vendor governance activities including issue management, release planning, enhancement prioritization, performance monitoring, SLA oversight, and system roadmap discussions.

·       Partner with IT and business stakeholders to identify opportunities for system optimization and automation.

·       Coordinate and oversee user acceptance testing (UAT), regression testing, production validation, and implementation activities.

·       Ensure system functionality supports operational workflows, regulatory requirements, audit readiness, and reporting needs.

Reporting, Analytics & Business Intelligence

·       Design, develop, automate, and maintain operational, compliance, quality, and executive-level dashboards and reporting solutions.

·       Create drill-down capabilities that allow leadership to monitor performance at enterprise, business unit, team, line-of-business, and case levels.

·       Translate business requirements into technical reporting specifications and data models.

·       Validate reporting accuracy and reconcile data across multiple systems and data sources.

·       Develop predictive monitoring tools and exception reports that identify emerging operational and compliance risks.

Regulatory Reporting & Audit Readiness

·       Serve as the primary owner of regulatory and audit-related data requests.

·       Develop, validate, and maintain CMS audit universes and related supporting documentation.

·       Coordinate data extraction and validation activities for regulatory submissions and audits.

·       Ensure all reporting methodologies are documented, reproducible, and defensible.

·       Support root cause analyses, corrective action plans, and remediation efforts resulting from audit findings.

·       Support implementation of new regulatory requirements through system enhancements, reporting modifications, and operational controls.

·       Ensure compliance reporting accurately reflects regulatory classifications, timeliness standards, notice requirements, and case outcomes.

Technology, AI & Automation

·       Identify opportunities to leverage artificial intelligence, machine learning, automation, and advanced analytics within A&G operations.

·       Partner with internal technology teams and vendors to implement AI-enabled workflow improvements.

·       Develop business requirements for API integrations between A&G systems and enterprise applications.

·       Evaluate emerging technologies and recommend solutions that improve scalability, audit readiness, reporting capabilities, and operational efficiency.

·       Support automation initiatives that reduce manual data manipulation and increase reporting accuracy.

Data Governance & Quality Management

·       Establish data governance standards for Appeals & Grievances reporting and analytics.

·       Develop automated monitoring processes that identify data anomalies and integrity concerns.

·       Partner with Data Analytics and IT teams to improve data quality and reporting consistency.

·       Ensure data definitions, reporting logic, and business rules are documented and maintained.

·       Support enterprise data governance initiatives affecting Appeals & Grievances operations.