Manager – Clinical Appeals and Grievances

🕒 July 29

🗽 New York, Tennessee, +2 more states – Remote

🗽 New York – Remote 🎸 Tennessee – Remote ⚔️ Virginia – Remote ⛰️ West Virginia – Remote

💵 $88.7k - $131.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 29%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

🛡️ Insurance

🏥 Healthcare

⚕️ Healthcare Insurance

Insurance • Healthcare • Healthcare Insurance

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

📋 Description

• Lead, operate, and advise the Clinical Appeals & Grievances team • Work with organizational leaders to identify priority focus areas, standardize and optimize processes, and communicate performance to stakeholders • Oversee internal and external production teams to ensure consistent production, quality, and compliance • Manage specialists through goal and productivity management, coaching, counseling, and performance management • Provide oversight and advice in case research • Interpret health plan policies, procedures, and regulations to guide specialists • Ensure timely case resolution and make critical decisions, with focus on clinical criteria for expedited cases • Standardize and optimize Appeals and Grievances routing and deploy approaches to meet production, compliance, and quality targets • Establish departmental goals, monthly goal reviews, and action plans for identified gaps • Guide preparation of cases for Medical Director Review, ensuring complete investigation information • Oversee case preparation for Maximus Federal Services, Fair Hearing, and External Appeal throughout the appeal process • Assist in leading the AOR / WOL Outreach team • Educate providers with Providers and DSE on timely and accurate Appeals submissions • Maintain delegated vendor relationships and ensure vendor performance and compliance measures • Identify and execute process improvements across operational areas • Diagnose operational challenges and skill gaps and provide team leadership • Identify trends, recommend improvements, and drive development of tools, systems, and processes • Maintain knowledge of industry trends, best practices, and protocols and collaborate across the enterprise on enhancements

🎯 Requirements

• Bachelor's degree from an accredited institution or equivalent work experience • RN • Experience with utilization management or appeals and grievance processing and compliance • Working experience in a fast-paced environment overseeing multiple priorities, tasks and/or teams • Proven track record of exercising independent thinking, ability to problem solve, understand process flows and correlating platforms to recommend and implement solutions • Experience preparing and delivering written and verbal information to multiple types of audiences • Demonstrated ability to build and foster effective relationships • Preferred: Experience in clinical practice with a focus in appeals & grievances, claims processing, utilization review or utilization management/case management • Preferred: Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines • Preferred: Extensive experience in healthcare appeals • Preferred: MBA or master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration • Preferred: Management experience in an operational department within the healthcare industry focused on clinical leadership • Preferred: Leadership experience in a focus area of operational excellence or audit • Preferred: Experience developing strategy and processes for a department or function • Preferred: Experience managing vendors as an extension of a core team • Preferred: Familiar with creating accountable ownership of a vendor team

🏖️ Benefits

• Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions