Healthfirst

The Appeals & Grievances (A&G) 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 A&G Dismissal 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 A&G Dismissal Specialist will manage his/her own caseload and is accountable for investigating and resolving member representative 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 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 non-par provider appeals.  The end to end process requires the Specialist to independently:
  • Research issues
  • Understand claim denials
  • Communicate with other departments to confirm submitter information
  • 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:

• Proven work experience with appeals and grievances or healthcare environment.
• Work experience demonstrating verbal and written communication skills.
• Customer service experience including resolving escalated customer complaints or concerns.
• Experience handling complex situations and/or projects.
• Proficient in Microsoft Office Suite applications including Excel, Word, Power Point, and Outlook.
• Working experience using MS Excel to sort, filter, and track trends with claims errors to provide resolution.
• Ability to work flexible hours, weekends, and evenings due to business needs.
• High School Diploma or GED from an accredited institution.

 Preferred Qualifications:

• Experience with OnBase
• Bachelor’s Degree from an accredited institution 
• Working experience using MS Excel to sort, copy and paste, as well as experience creating and using pivot tables.
• Frequently communicates complex information and interacts with management. Can present, resolve conflicts, and address delicate situations.

Compliance & Regulatory Responsibilities: See Above

License/Certification: N/A

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.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.