Associate III A&G Analyst (Full Time)

JOB SUMMARY The IRE Analyst is responsible for reviewing appeal cases to ensure compliance with regulatory requirements and quality standards. This role performs quality audits, identifies process improvement opportunities, and provides feedback to support accurate, timely, and compliant case handling. The analyst works closely with Appeals & Grievances Quality team, and Supervisor to promote quality outcomes and member satisfaction. KEY RESPONSIBILITIES • Conduct quality reviews of appeals cases for accuracy, completeness, and regulatory compliance. • Evaluate case documentation to ensure adherence to organizational policies, CMS, state, federal, and client requirements. • Audit correspondence, determination letters, case notes, and supporting documentation. • Verify that case processing timelines and service-level agreements (SLAs) are met. • Identify errors, compliance risks, and opportunities for process improvement. • Monitor trends and recommend corrective actions for recurring quality issues. • Escalate high-risk findings, compliance concerns, and systemic issues to leadership. • Maintain confidentiality and protect sensitive members and health information in accordance with HIPAA requirements. Required Qualifications • Associate's degree preferred. • 0-2 years of experience in quality assurance, appeals and grievances, healthcare operations, claims, customer service, or a related field. • Basic understanding of healthcare regulations and compliance requirements. • Strong analytical and problem-solving skills. • Excellent attention to detail and accuracy. • Effective written and verbal communication skills. • Experience using Microsoft Office applications, including Excel, Word, and Outlook. • Ability to organize and prioritize multiple assignments in a deadline-driven environment. Preferred Qualifications • Experience in Medicare, Medicaid, Commercial Health Plans, or Managed Care. • Familiarity with CMS regulations and appeals and grievance processes. • Knowledge of quality monitoring systems and audit methodologies. • Experience with case management applications and workflow systems. • Understanding of HIPAA privacy and security requirements.