Appeals and Grievances, Non-Clinical Specialist (High-Volume)

The Appeals and 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. Appeals and Grievances works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

The Appeals and Grievances 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 issues
  • Reference and understand HF’s internal health plans’ policies and procedures to frame decisions
  • Interpret regulations
  • Resolve cases and make critical decisions
  • Edit and finalize resolution letters
  • Manage all duties within regulatory timeframes
  • Communicate effectively to hand-off or pick-up work from colleagues
  • Work within a framework that measures productivity and quality for each Specialist against expectations
     
• Additional duties as assigned.

Minimum Qualifications

• Bachelor’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 Insurance.
• Work experience in claims, customer service, home health, hospital or doctor’s office preferred.
• Experience working in care management systems, such as CCMS, TruCare or Hyland.
• Demonstrated critical thinking and decision-making competencies.
• Highly effective communication, organizational, and customer service skills.
• Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes.

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.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within HF Management Services, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with HF Management Services,  LLC.

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