Healthfirst

The Sr. Account Manager, Provider Complaints is an integral role that successfully manages escalated provider complaints as assigned. Reporting directly to the Sr. Manager, Complaint Resolution, they will be dedicated to (1) expediting the research of formally reported provider complaint (2) contacting providers to negotiate single case agreements and working through the various complaint details and (3) working with the appropriate internal stakeholders to close out all aspects of the complaints. In this role, the Sr. Account Manager, Provider Complaints deals with providers that require one-time resolution as well as serves as a single point of contact for Out of Network providers who have submitted a formal complaint. The Sr. Account Manager will drive results that increase provider satisfaction and reduce/eliminate repeat complaints from assigned providers. Efforts directly impact the improvement of CMS STAR ratings.

Duties & Responsibilities: 

• Serve as internal point of contact for cross-functional internal departments and teams to ensure all provider complaints are addressed and resolved within established guidelines  
• Partners with Sr. Complaint Analyst, and performs root cause analysis, to ensure effective identification of contributing complaint issues 
• Performs all tracking and trending of activity on managing root cause inventory, as well as resolution of all root cause issues identified
• Communicate complaint resolution results to key stakeholders 
• Drafts complex complaint summaries and speaking points to ensure Regulatory can effectively respond to external agencies regarding all aspects of a complaint 
• Makes recommendations on strategy and process improvement to drive successful outcomes of assigned complaints 
• Negotiates complex single case agreements and settlements with complex providers as needed to resolve a complaint 
• Works cross functionally to assist with resolution of complex claims related issues 
• Tracks all aspects of provider complaints and ensures all assigned deadlines are met 
• Serves as a subject matter expert for Delivery System Engagement on resolution of provider complaints
• Additional duties as assigned 

Minimum Qualifications: 

• Network Management / Provider Relations experience with Hospital, Physician, Ancillary and/or Behavioral Health providers  
• Familiarity with reimbursement methodologies (DRG, FFS, Capitation, APG, APC) 
• Experience with resolution of reported provider complaints 
• Managed Care operations experience working with various business partners to facilitate resolution (Legal, Regulatory/Compliance, Claims) 
• Resolution of root cause contributing to provider complaints 
• Work experience with MS Excel, Word, Power Point 
• Bachelor’s Degree from an accredited institution or equivalent work experience 

Preferred Qualifications: 

• Cross functional experience in working as a liaison to internal business partners 
• MS Visio 
• Critical thinking skills 
• Great attention to detail 
• Master’s Degree from an accredited institution 

Compliance & Regulatory Responsibilities: Noted above 

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $103,400 - $149,430

• All Other Locations (within approved locations): $88,700 - $131,920

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.