Healthfirst

The Appeals & Grievances (A&G) Non-Clinical Team Leader is the subject matter expert responsible for overseeing the execution and performance of a team who investigates and resolves member complaints, grievances and/or appeals that are presented by the member or provider pertaining to authorization or delivery of clinical and non-clinical services. This role supports Healthfirst’s commitment to delivering high-quality member experience by ensuring that issues are thoroughly researched, properly documented, accurately classified, and resolved within applicable regulatory timeframes. The incumbent provides day-to-day guidance, coaching, workload oversight, quality review, and operational support to a team responsible for non-clinical case development and resolution. This includes helping specialists retrace the member experience, gather facts and documentation, collaborate with internal and external business partners, apply applicable policies and regulations, and produce clear, accurate, resolution letters.  

This position requires three days per week in office, Tuesday through Thursday, at 100 Church Street, New York, NY.

Duties/Responsibilities: 

• Lead and support a team responsible for investigating and resolving non-clinical appeals and/or grievances
• Manage team performance, including productivity, quality, timeliness, case progression, and adherence to regulatory requirements
• Provide coaching, feedback, and day-to-day guidance to help specialists strengthen critical thinking, investigative skills, written communication, and case resolution quality
• Review and support case development to ensure issues are thoroughly researched, accurately documented, properly classified and categorized, and resolved based on applicable policies, procedures, and regulatory requirements
• Ensure specialists issue timely acknowledgement letters, requests for information, and resolution letters in accordance with regulatory and organizational standards
• Support the drafting, review, and finalization of clear, accurate, grammatically correct correspondence
• Monitor case inventory trends, workload distribution, aging, and priority cases to ensure work is assigned appropriately based on skill, training, complexity, and business need
• Identify barriers to timely case resolution and collaborate with internal departments, vendors, and external partners to resolve issues
• Support onboarding and training for new hires and provide ongoing education to existing staff as policies, procedures, systems, or regulatory requirements change
• Assist with performance management, including coaching, counseling, documentation, and escalation of performance concerns as appropriate
• Promote a culture of accountability, continuous improvement, professionalism, collaboration, and member-centered problem solving
• Support quality assurance activities, audit readiness, reporting, process improvement initiatives, and other operational priorities as assigned
• Interpret and apply health plan policies, procedures, benefit information, and relevant state and federal requirements to support compliant grievance resolution 
• Use available systems, tools, reporting, and technology to monitor work, identify trends, and improve team performance
• Perform additional duties as assigned

Minimum Qualifications:

• High School Diploma or GED from an accredited institution
• Experience in healthcare operations, managed care, health insurance, grievances, complaints, appeals, claims, member services, provider services, care management, or a related regulated operational environment
• Work experience demonstrating written and verbal communication that is clear, concise, grammatically correct, and professional
• Work experience requiring critical thinking, problem-solving, and deductive reasoning skills
• Work experience requiring self-reliance, attention to detail, meeting deadlines, and managing multiple priorities simultaneously
• Work experience using Microsoft Office applications including Word, Excel, Outlook, Teams, and PowerPoint 

Preferred Qualifications:

• Associate or bachelor’s degree
• Prior leadership experience in healthcare, managed care, health plan, payer, provider, or regulated operations environment
• Experience leading, coaching, or supervising a team responsible for casework, complaints, grievances, appeals, claims, or member issue resolution
• Experience with Medicare, Medicaid, Commercial, Marketplace, or other regulated health plan products
• Experience with claim processing, claim denials, billing, coding, provider payment, or reimbursement operations
• Experience supporting audits, quality reviews, process improvement initiatives, or regulatory readiness activities
• Strong professional presence and ability to present information clearly to leaders or cross-functional partners
• Familiarity with artificial intelligence tools or demonstrated interest in using technology to improve quality, efficiency, or team performance

Compliance & Regulatory Responsibilities: N/A

License/Certification: N/A

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620

• All Other Locations (within approved locations): $61,300 - $89,440

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.