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Appeals and Grievances Specialist, Non Clinical

Job Category: Appeals & Grievances

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Location: Lake Mary, FL, United States

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Job Description


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.

This is full-time on-site position located at 1101 Greenwood Avenue, Lake Mary, Florida.

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 time-frames
    • 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. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

    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 [email protected] 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 Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

    EEO Law Poster and Supplement

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