Grievance Specialist – Remote

Healthfirst is seeking a Grievance Specialist to join its Appeals & Grievances (A&G) team in a fully remote position. The role focuses on managing and resolving member or authorized representative complaints and grievances across various healthcare programs, including Medicare, Medicaid, Child Health Plus, Commercial Plans, and other Healthfirst products.

The selected candidate will be responsible for investigating concerns, coordinating with internal departments and external partners, preparing compliant resolution communications, and ensuring cases are handled accurately and within required timelines. This position plays an important role in supporting members and improving healthcare service experiences.

• Manage assigned grievance cases throughout the complete lifecycle, including acknowledgement, investigation, resolution, and member communication.
• Conduct detailed research by collaborating with internal teams such as Member Services, Provider Operations, Clinical, Enrollment, and Pharmacy departments.
• Work with external vendors and service partners to resolve member concerns related to additional benefits and contracted services.
• Prepare clear acknowledgement and resolution letters while ensuring compliance with regulatory requirements.
• Maintain accurate case documentation according to company policies, audit standards, and regulatory guidelines.
• Monitor case progress and ensure timely completion of assigned grievances.
• Participate in team meetings, quality reviews, training sessions, and performance evaluations.
• Achieve department productivity and quality performance targets.

• High School Diploma or GED from an accredited institution.
• Understanding of utilization management processes and how service authorizations impact healthcare access and claims payments.
• Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, Outlook, and case tracking systems.
• Strong written and verbal communication skills.
• Ability to manage multiple cases and meet deadlines in a remote work environment.
• Strong knowledge of:
  • Healthcare grievance and complaint resolution processes.
  • Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and Qualified Health Plans.
  • Healthcare claims processing and provider billing workflows.
  • CMS regulations and applicable healthcare compliance requirements.
• Bachelor's Degree or equivalent experience in healthcare, public health, or a related field is preferred.
• Experience with long-term services and supports (LTSS), including PCS and CDPAS, is an advantage.
• High School Diploma or GED Required;
  Bachelor's Degree in Healthcare, Public Health, or Related Field Preferred