Grievance and Appeals CTM Analyst

Position Summary

The Grievance and Appeals CTM Analyst is responsible for reviewing, investigating, tracking, and resolving member complaints. This position supports regulatory compliance by ensuring complaints received through the Centers for Medicare & Medicaid Services (CMS) Complaint Tracking Module (CTM) are thoroughly researched, accurately documented, and resolved within established regulatory and organizational timeframes.

The analyst works collaboratively with internal departments, delegated entities, providers, and other stakeholders to investigate complaint issues, identify appropriate resolutions, and ensure timely and accurate responses. The role requires strong attention to detail, critical-thinking skills, knowledge of Medicare Advantage operations, and the ability to interpret and apply CMS requirements and health plan policies.

Essential Responsibilities Review and investigate member complaints received through the CMS Complaint Tracking Module (CTM) and other applicable channels. Analyze complaint information, member history, claims, authorizations, provider records, correspondence, and other documentation to determine the facts and appropriate resolution.

Conduct research and coordinate with internal departments and delegated entities to obtain information necessary to resolve complaints. Identify potential compliance, operational, service, access-to-care, claims, authorization, provider, or benefit-related issues. Document investigative findings, actions taken, and resolutions accurately and completely within applicable tracking systems.

Monitor assigned complaints to ensure they are addressed within required CMS and organizational turnaround times. Review documentation for accuracy, completeness, consistency, and compliance with applicable requirements. Communicate findings and resolution recommendations to appropriate departments and stakeholders. Escalate complex, sensitive, or potentially non-compliant issues to management or the appropriate compliance department.

Identify recurring complaint trends and potential root causes that may require corrective action or process improvement. Assist with complaint reporting, audits, quality reviews, and regulatory inquiries as needed. Maintain confidentiality and handle protected health information in accordance with organizational policies and applicable privacy requirements.

Participate in process-improvement initiatives designed to improve member experience, complaint resolution, and regulatory compliance. Maintain current knowledge of plan requirements, CMS guidance, organizational policies, and applicable complaint and grievance procedures.

Qualifications

High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, public health, or a related field preferred. Experience in Medicare Advantage, managed care, health insurance, healthcare operations, member services, grievances and appeals, quality, or compliance preferred.

Familiarity with CMS requirements and Medicare Advantage operations preferred. Experience reviewing and investigating member complaints or conducting case research strongly preferred. Strong analytical, organizational, and problem-solving skills. Excellent written and verbal communication skills. Ability to interpret policies, procedures, and regulatory requirements.

Strong attention to detail and ability to manage multiple cases and deadlines simultaneously. Proficiency with Microsoft Office and healthcare-related databases or case-management systems. Core Competencies CMS & Regulatory Compliance Complaint Investigation Critical Thinking & Problem Solving Case Management & Documentation Attention to Detail Member Advocacy Cross-Functional Collaboration Time Management Written Communication Root Cause Analysis