The Appeals and Grievances unit manages Healthfirst member complaints, grievances and appeals that are presented by the member or provider pertaining to the authorization of or delivery of clinical and non-clinical services. A&G works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner. The Appeals and Grievances Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The Appeals and Grievances Specialist will manage his/her own caseload and is accountable for investigating and resolving member or provider initiated cases. Manages all Department of Health (DOH) and executive complaints as needed. The incumbent may also handle non-clinical claim appeals that come from Healthfirst participating and non-participating providers.

Duties and Responsibilities

• Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end to end process requires the Specialist to independently:
• Research issues
• Reference and understand HF’s internal health plans’ policies and procedures to frame decisions
• Interpret regulations
• Resolve cases and make critical decisions
• Edit and finalize resolution letters
• Manage all duties within regulatory timeframes
• Communicate effectively to hand-off or pick-up work from colleagues
• Work within a framework that measures productivity and quality for each Specialist against expectations
• Additional duties as assigned

Minimum Qualifications

• Bachelor’s degree from an accredited institution or relevant work experience

Preferred Qualifications

• Minimum of two (2) years of work experience in Managed Care or Health Insurance
• Work experience in claims, customer service, home health, hospital or doctor’s office preferred
• Experience working in care management systems, such as CCMS, TruCare or Hyland
• Demonstrated critical thinking and decision-making competencies
• Highly effective communication, organizational, and customer service skills
• Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960
• All Other Locations (within approved locations): $49,795 - $72,800

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

• Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end to end process requires the Specialist to independently:
• Research issues
• Reference and understand HF’s internal health plans’ policies and procedures to frame decisions
• Interpret regulations
• Resolve cases and make critical decisions
• Edit and finalize resolution letters
• Manage all duties within regulatory timeframes
• Communicate effectively to hand-off or pick-up work from colleagues
• Work within a framework that measures productivity and quality for each Specialist against expectations
• Additional duties as assigne