Description and Requirements Position Summary: 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 Clinical Specialist is the subject matter expert responsible for all clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. The incumbent 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 clinical claim appeals that come from Healthfirst participating and non-participating providers.

Duties and Responsibilities:

Responsible for case development and resolution of clinical cases, such as: Pre-existing Conditions, Prior Approval, Medical Necessity, Pre-certification, Continued Stay, Reduction, Termination, and Suspension of services. The end to end process requires the Specialist to independently:Research issuesQuality of Care ExperienceReference and understand HF’s internal health plans policies and procedures to frame decisionsInterpret regulationsResolve cases and make critical decisionsUpdate file documentation such as the file notes and case summaryManage all duties within regulatory timeframesCommunicate effectively to hand-off and pick-up work from colleaguesWork within a framework that measures productivity and quality for each Specialist against expectationsPrepare cases for Medical Director Review ensuring that all pertinent information (i.e. case summary, contract information, internal and external responses, diagnosis, and CPT codes and descriptions) has been obtained during investigation and is presented as part of the casePrepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal processAdditional duties as assigned

Minimum Qualifications:

 RN , LPN OR Dental Hygienist

Preferred Qualifications:

Bachelor’s degreeExperience 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 guidelinesAbility to work independently on several computer applications such as Microsoft Word and Excel, as well as corporate email and virtual filing system, (ie. Macess). Experience with care management systems, such as CCMS, TruCare and Hyland.Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment

Hiring Range*:

Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480

All Other Locations (within approved locations): $71,594 - $106,080

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.