Manager, Clinical Appeals & Grievances

Duties & Responsibilities:

• Prepare and plan the weekend staffs assignments and volume to ensure compliance

• Triage and assign expedited appeals while helping standardize and optimize how Appeals and Grievances are routed

• Manage inventory to ensure regulatory compliance for appeals processed through the weekend

• Communicate and escalate cases to Medical Peer reviewers

• Maintain delegated vendor relationships and ensure vendor performance and compliance measures are met

• Coordinate with outside departments for case escalation, clarifications and collaboration needed for appeal resolution

• Manage letter review and printing and coordinate with the mailroom for expedited printing needs

• Review case change requests and cancellations including appropriate routing for follow up

• Review and submit Level 2 appeals packets to the appropriate entity

• Maintain knowledge of industry trends, best practices and protocols and share with other units comprising the enterprise to ensure general consistencies and enhancements

• Identify trends and recommend solutions for improvement

• Maintain best practices and strategically deploy approaches to meet production, compliance and quality targets to perform all Appeals & Grievances tasks

• Build partnerships with business areas across and outside of operations to improve communication and responsiveness to multiple conflicting resource demands

• Provide feedback and recommendations to leadership concerning staff performance

• Comply with HIPAA guidelines and maintain confidentiality of member, provider, medical and departmental information.

• Adhere to state and federal compliance and regulatory guidelines

• Additional duties as assigned

Minimum Qualifications:

• H.S. Diploma or GED

• Proven work experience with appeals and grievances or a healthcare environment

• Work experience demonstrating verbal and written communication skills

• Experience working independently in a fast-paced environment that requires handling multiple priorities simultaneously

• Willing and able to work a weekend schedule (i.e. Fri-Mon or Thurs-Sun)

• Work experience using several computer applications such as Microsoft Word and Excel, corporate email and virtual filing systems (ie. Macess), and experience with care management systems, such as CCMS, TruCare and Hyland.

Preferred Qualifications:

• Bachelors degree

• RN or LPN strongly preferred

• Experience in clinical practice with experience 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 guideline

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. 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.