Marketplace Appeals & Compliance Analyst

Position Overview

The Marketplace Appeals & Compliance Analyst represents Get Covered Illinois (GCI) in Marketplace appeals, performing advanced analysis and problem-solving related to the application and administration of healthcare programs under the Affordable Care Act. This position supports the administration of the GCI Marketplace appeals program, while also assisting in conducting compliance monitoring, investigating privacy and compliance issues, coordinating audits, and enforcing federal and state policies. The incumbent ensures adherence to federal and state laws, tracks appeals trends, identifies process improvements, and delivers training as needed. This role requires collaboration with internal and external stakeholders, including legal, data privacy, and security teams, to safeguard sensitive appeals-related data and uphold a culture of compliance and ethics across GCI. The position demands advanced and integrated knowledge of appeals regulatory and legal processes, program compliance, and privacy requirements. Working in a high-volume, data- and deadline-driven environment, the incumbent researches, analyzes, and applies relevant factors affecting program eligibility to resolve complex appeals issues. Problem-solving frequently entails interpreting agency policy, federal and state law, and regulatory guidance to novel factual situations, with each case presenting unique challenges.

Get Covered Illinois is the State of Illinois’s new Health Insurance Marketplace. Get Covered Illinois’s mission is to increase access, enrollment, affordability, and choice for individuals and families by connecting them to health insurance plans and savings available through the Affordable Care Act. Get Covered Illinois provides pathways to coverage through a consumer-centric online application platform, a Customer Assistance Center, localized outreach and education strategies and a network of in-person assisters embedded in communities across the state that help Illinoisans enroll in the coverage that best meets their families’ needs. Get Covered Illinois is part of the Illinois Department of Insurance and has offices in Chicago and Springfield.

Essential Functions

• As a State-Based Marketplace Appeals Analyst, assists with appeals or Resolution Review operations and independently processes appeals or Resolution Review cases and duties related to such.  Provides technical expertise for the appeals or Resolution Review operations for the Marketplace.  
• Performs detailed case research and analysis related to appeals and Resolution Review requests and determines eligibility for certain Illinois health care programs.
• Provides general compliance monitoring and audit support, and assists with data coordination and privacy/security collaboration.
• Assists with training and staff developments to ensure compliance standards and needs are met.
• Serves as liaison between GCI’s Compliance and Program Oversight team and the Department of Insurance’s (DOI) Legal team.
• Performs other duties as required or assigned which are reasonably within the scope of the duties enumerated above.

Minimum Qualifications

• Requires knowledge, skill, and mental development equivalent to completion of four (4) years of college, preferably with coursework in business or public administration.
• Requires one (1) year of responsible administrative experience in a public or business organization, or completion of an agency approved professional management training program.

Preferred Qualifications

• Prefers at least two (2) years of experience preparing documentation, submitting evidence, and representing an agency or organization in administrative hearings, including providing testimony and advocating on behalf of an agency in a prosecutorial capacity.
• Prefers at least two (2) years of experience drafting or implementing compliance policies, procedures, or monitoring tools in a healthcare or another setting, including evaluating compliance or privacy complaints, applying knowledge of Medicaid, government healthcare programs, or other regulatory programs, and analyzing and interpreting statutes, rules, and policies to ensure compliance in complex or evolving regulatory environments.
• Prefers at least one (1) year of experience with administrative appeals processes, including tracking, analyzing, and recommending process improvements, and applying knowledge of Medicaid, other government healthcare programs, or other regulatory programs.
• Prefers at least two (2) years of experience designing or implementing compliance programs, including policy compliance checks, corrective action planning, supporting audits, and monitoring performance metrics to ensure program integrity.
• Prefers at least two (2) years of experience demonstrating strong oral and written communication skills, coordinating with multiple stakeholders (e.g., state/federal agencies, IT vendors, carriers), delivering training, and serving as a liaison with legal and compliance teams.
• Prefers at least two (2) years of experience managing caseloads, prioritizing tasks, and performing work in healthcare, law-related, or other regulated fields, demonstrating the ability to handle complex administrative and compliance matters effectively.

Specialized Skills

• Requires at least two (2) years of experience preparing documentation, submitting evidence, and representing an agency or organization in administrative hearings, including providing testimony and advocating on behalf of an agency in a prosecutorial capacity.
• Requires at least two (2) years of experience drafting or implementing compliance policies, procedures, or monitoring tools in a healthcare or another setting, including evaluating compliance or privacy complaints, applying knowledge of Medicaid, government healthcare programs, or other regulatory programs, and analyzing and interpreting statutes, rules, and policies to ensure compliance in complex or evolving regulatory environments.

Conditions of Employment

• Requires the ability to pass a background check.
• Requires ability to travel in the performance of duties, with overnight stays as appropriate.
• The conditions of employment listed here are incorporated and related to any of the job duties as listed in the job description.
• Certain provisions of the revolving door restrictions contained in 5 ILCS 430/5-45 apply to this position. As a result, the employee should be aware that if offered non-State employment during state employment or within one year immediately after ending State employment, the employee shall, prior to accepting any such non-State employment offer, notify the Office of the Executive Inspector General for the Agencies of the Illinois Governor (OEIG) or may be subject to a fine.

About the Agency

The Department of Insurance (DOI) regulates the insurance market in the State of Illinois including, but not limited to, licensing and educating insurance agents, investigating Workers Compensation fraud, and examining the operations and finances of insurance companies domiciled in the state. We are committed to protecting consumers and regulating the insurance industry with innovation and efficiency. DOI has approximately 220 employees who are split between our Chicago and Springfield offices.

State of Illinois employees enjoy a robust benefit package, including:

• Health, Life, Vision, and Dental Insurance
• 13 Paid Holidays annually, 14 on even numbered years
• 10-25 days of Paid Vacation time annually - (10 days in year one of employment)
• 12 Paid Sick Days annually (sick days carry over from year to year)
• 12 Weeks Paid Maternity/Paternity Leave
• 3 Paid Personal Days annually
• Pension Plan
• Deferred Compensation Program and other pre-tax benefit programs (Medical/Daycare)
• Flexible work schedules may be available, dependent upon position
• Tuition Reimbursement Program and Federal Public Service Loan Forgiveness Program eligibility

Visit https://www2.illinois.gov/cms/benefits/Pages/default.aspx for more information about our benefits.