Appeals Specialist

The Appeals & Grievances (A&G) unit processes member and non-contracted provider appeals for all of HF's line of businesses which include commercial, Medicaid, dual enrollments, Medicare and complete care. Appeals Specialists are the subject matter experts responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. Key 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 Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes. Prepare and submit well documented appeals in accordance with payer guidelines and within timely filing limits Identify patterns or trends in denials and provide feedback for leadership for process improvement. Remain up to date on payer policies, industry regulations and coding updates to ensure compliance and maximize reimbursement Additional duties as assigned Minimum Qualifications HS Diploma or GED from an accredited institution Minimum of two (2) years of work experience in Managed Care Health Insurance Plan Experience with appeals for Medicare, Medicaid, Dual enrollment and commercial Plans end to end Claims processing experience with coding criteria is preferred. This includes the auto forwarding of upheld cases to the respective regulatory independent reviewer for denied cases Preferred Qualifications Bachelor's degree from an accredited institution or relevant work experience Demonstrated critical thinking and decision-making competencies 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 View email address on click.appcast.io or calling View phone number on click.appcast.io. 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. Know Your Rights All hiring and recruitment at Healthfirst is transacted with a valid "@healthfirst.org" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process. Hiring Range Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070 All Other Locations (within approved locations): $51,000 - $74,880 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. #J-18808-Ljbffr Remote Jobs