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 Specialist is the subject matter expert responsible for non-clinical case development and case resolution while ensuring compliance with Federal and/or State regulations. They manage their own caseload and are accountable for investigating and resolving member or non-contracted provider-initiated cases. 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 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. 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. #J-18808-Ljbffr