Manager, Clinical Appeals & Grievances

The Appeals & Grievances (A&G) Weekend Inventory Manager is responsible for managing and monitoring appeal inventory for a team of A&G Clinical Specialist. This is a full-time role, expected to work 4 days a week and must be able to work the weekends (i.e. Fri-Mon or Thurs-Sun). The incumbent works closely with multiple leaders in the organization to monitor and drive internal and external production teams to ensure consistent output, high quality and to maintain compliance on all levels. The Weekend Inventory Manager will utilize strategic thinking and creativity to address challenges in alignment with long term growth and profitability goals of Healthfirst.

Duties & Responsibilities

Prepare and plan the weekend staff’s 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 escape 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

Bachelor’s 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

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. 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): $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. Healthfirst is New York’s largest not-for-profit health insurer offering it’s nearly 1.7 million members access to high-quality, affordable healthcare. As part of the community for nearly 30 years, Healthfirst’s unique advantage is rooted in its belief that good health doesn’t start in a doctor’s office. The company’s mission is to put its members first by working closely with care providers and community leaders to address broader issues that can impact health and well-being. This value-based care model is the foundation of the company’s sustained growth in one of the most dynamic markets in the country. So, if you are passionate about what you do and want to work for a company that is focused on the future and dedicated to making a difference in people’s lives, then Healthfirst is for you.