Healthfirst

The Manager, Clinical Appeals & Grievances is responsible for leading, operating, and advising a dynamic and fast-paced Clinical Appeals & Grievances team. This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee internal and external production teams to ensure consistent production, high quality and to maintain compliance on all levels. This role will remain flexible while utilizing strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

Duties and Responsibilities:

• Manages a team of specialists, with responsibility for goal and productivity management, coaching and counseling, performance management and other leadership responsibilities as assigned

• Provides oversight in case research and provides advice as needed

• Understands HF’s internal health plans’ policies and procedures to frame decisions

• Interprets regulations to provide guidance to specialists on a daily basis

• Ensures the timely resolution of cases and makes critical decisions

• Focuses on clinical criteria for expedited cases

• Helps standardize and optimize how Appeals and Grievances are routed

• Determine best practices and strategically deploy approaches to meet production, compliance and quality targets

• Works with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps

• Provides guidance in the preparation of case preparation for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the case

• Has oversight in case preparation for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process

• Assists in leading the AOR / WOL Outreach team in coordination with the supervisor

• Works with Providers and DSE on educating providers in how to submit Appeals timely and accurately.

• Maintains delegated vendor relationship and ensure vendor performance and compliance measures are met

• Institutes and manages working relationships within various operational areas to identify and execute overall process improvements

• Diagnoses and understands operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team

• Identifies trends and recommends solutions for improvement.

• Drives the development of innovative tools, systems, and processes to assist in overall handling of Appeals & Grievances functions

• Maintains knowledge of industry trends, best practices and protocols and collaborating with other parts of the enterprise to ensure general consistencies and enhancements

• Additional duties as assigned

Minimum Qualifications:

• Bachelor's degree from an accredited institution or equivalent work experience

• RN or LPN

• Experience with utilization management or appeals and grievance processing and compliance

• Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams

• Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions

• Experience preparing and delivering written and verbal information to multiple types of audiences

• Demonstrated ability to build and foster effective relationships

Preferred Qualifications: 

• Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management.

• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines

• Extensive experience in healthcare appeals

• MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration

• Management experience in an operational department within the healthcare industry focused on clinical leadership

• Leadership experience in a focus area of operational excellence or audit

• Experience developing strategy and processes for a department or function

• Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $100,900 - $145,775

• All Other Locations (within approved locations): $86,500 - $128,690

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. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.