A&G Dismissal Specialist

Description and Requirements

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 Dismissal Specialist conducts outreaches to members, member representatives, and non-contracted providers as applicable while ensuring compliance with Federal and/or State regulations. The A&G Dismissal Specialist will manage his/her own caseload and is accountable for adhering to the process outlined in the job aid. The team handles all member representative-submitted grievances and standard appeals, as well as all post-service reconsiderations submitted by non-contracted providers.

Duties and Responsibilities

• Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and non-par provider appeals. The end to end process requires the Specialist to independently:
  • Research issues
  • Understand claim denials
  • Communicate with other departments to confirm submitter information
  • Reference and understand HF's internal health plans' policies and procedures to frame decisions
  • Interpret regulations
  • Dismiss cases and make critical decisions
  • Edit and finalize outreach and/or dismissal 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
• Additional duties as assigned

Minimum Qualifications:

• Proven work experience with appeals and grievances or healthcare environment.
• Work experience demonstrating verbal and written communication skills.
• Customer service experience including resolving escalated customer complaints or concerns.
• Demonstrated ability to be highly organized with attention to detail
• Experience handling complex situations and/or projects.
• Proficient in Microsoft Office Suite applications including Excel, Word, Power Point, and Outlook.
• High School Diploma or GED from an accredited institution.

Preferred Qualifications:

• Experience with OnBase
• Bachelor's Degree from an accredited institution
• Frequently communicates complex information and interacts with management.
• Can present, resolve conflicts, and address delicate situations.

Compliance & Regulatory Responsibilities: See Above

License/Certification: N/A

Hiring Range:

• Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960
• All Other Locations (within approved locations): $49,795 - $72,800

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.

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, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.