Healthfirst

The Appeals Review Specialist is responsible for independently managing a caseload, preparing appeal packets for external review, and ensuring timely, compliant resolutions in accordance with state and federal regulations. This role requires that appeal cases and independent review inquiries are processed, accurately, thoroughly, and within required timeframes while upholding company polices and regulatory standards. The specialist will serve as a point of contact with various regulators, entities and providers to ensure that request are handled accurately and timely while upholding company policies and regulatory standards.

Key Responsibilities:

• Research issues and apply Healthfirst policies, procedures, and regulations.
• Prepare, edit, and finalize case files, letters, and summaries.
• Manage all duties within regulatory timeframes.
• Manage the Independent Dispute Resolution (IDR) process by effectively monitory submissions, timelines and ensuring compliance to achieve fair and timely resolution of payment disputes .
• Communicate and collaborate effectively with colleagues.
• Efficiently manage the external appeal process from beginning to effectuation of the resolution of the external appeal decision.
• Ensure accuracy in OnBase cases, including:
  • Correct org received/decision date and time.
  • Proper setup as Pre- or Post-service.
  • Verification of service level and authorization number.
  • Accurate member and submitter demographics.
  • Complete provider details with address.
• Complete case summaries with all fields checked and service level validated.
• Confirm inclusion of required documents (assessments, denial rationale, EOC excerpts, redacted pages).
• Gather information from OnBase, TruCare, and other systems; maintaining accurate case management.
• Build evidence packets per job aid (AG-RF-208), ensuring correct order and attachments.
• Submit packets to OAH via FTP by due date and upload proof of submission upon acknowledgement.
• Maintain productivity, quality standards, and HIPAA compliance.
• Perform additional duties as assigned.

Minimum Qualifications

• HS Diploma or GED from an accredited institution  

• Experience in claims, customer service, or healthcare settings

• Collaborative

• Detail-oriented, able to work under pressure, and meet tightlines

• Ability to work under pressure

• Organized

Preferred Qualifications:

• Previous experience in managed care, health insurance, or appeals.
• Familiarity with systems such as OnBase, TruCare, or Hyland.
• Strong critical thinking, decision-making, and communication skills.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070

• All Other Locations (within approved locations): $51,000 - $74,880

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.