Description and Requirements 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 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 Specialist will manage his/her own caseload and is accountable for investigating and resolving member or provider-initiated 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 participating and 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 member and provider appeals.  The end-to-end process requires the Specialist to independently:Research issuesReference and understand HF’s internal health plans’ policies and procedures to frame decisionsInterpret regulationsResolve cases and make critical decisionsEdit and finalize resolution lettersManage all duties within regulatory timeframesCommunicate effectively to hand-off or pick-up work from colleaguesWork within a framework that measures productivity and quality for each Specialist against expectationsAdditional duties as assigned

Minimum Qualifications

High School Diploma or GEDBachelor’s degree from an accredited institution or relevant work experience

Preferred Qualifications

Minimum of two (2) years of work experience in Managed Care or Health InsuranceWork experience in claims, customer service, home health, hospital or doctor’s office preferredExperience working in care management systems, such as CCMS, TruCare or HylandDemonstrated critical thinking and decision-making competenciesHighly effective communication, organizational, and customer service skillsDemonstrated ability to be detail oriented, work under pressure, manage tight timeframes

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.