Appeals and Grievances Clinical Specialist

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. This is either a remote or on-site position located at either the 100 Church Street location in New York City or the 1101 Greenwood Avenue location, Lake Mary, Florida.

This position may require attendance at A&G/ Operations divisional meetings and Town Halls, some of which may require travel to one of the locations (T&E will be covered according to policy).

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 issues

Reference and understand HF’s internal health plans policies and procedures to frame decisions

Interpret regulations

Resolve cases and make critical decisions

Update file documentation such as the file notes and case summary

Manage all duties within regulatory time frames

Communicate effectively to hand-off and pick-up work from colleagues

Work within a framework that measures productivity and quality for each Specialist against expectations

Prepare 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 case Prepare cases for Maximus Federal Services, Fair Hearing, and External Appeal through all levels of the appeal process

Additional duties as assigned

Minimum Qualifications:

RN , LPN OR Dental Hygienist

Preferred Qualifications:

Bachelor’s degree

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), Inter Qual, Milliman or Medicare local coverage guidelines

Ability 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, Tru Care and Hyland.

Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment 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…